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A  TREATISE 


ON 


HEADACHE  AND  NEURALGIA, 


INCLUDING 


SPINAL  IRRITATION  AND  A  DISQUISITION 
ON  NORMAL  AND  MORBID  SLEEP. 


BY 

J.    LEONARD    COKNING,    M.A.,    M.D., 

Consultant  in    Nervous   Diseases  to   St.  Francis  Hospital  ;  Fellow  of  the  New 
York  Acadenn   of  Medicine  ;   Member  of  the  New  York 
Neurological  Society  ;  etc. 

AUTHOR  OP 

"A  Treatise  on  Hysteria  and  Epilepsy,"  "  Local  Anaesthesia,"  "  Brain  Rest,"  etc. 
WITH    AN    APPENDIX. 

Eye   Strain,   a   Cause,  of   Headache, 
By   DAVID   WEDSTER,   M.D., 

Prof,   of  Ophthalmology  ia  the  New  York   Polyclinic  ;   Surgeon  to  the  Manhat- 
tan  Eye  and   Ear  Hospital,   etc.,    etc. 


ILLUSTRATED. 
THIRD    EDITION. 

NEW     YORK  : 

E.  B.  TREAT,   5  COOPER  UNION, 

London  :    H.    K.    Lewis,    136    Grower    Street. 

1894. 

Price,  $2.75, 


I?C  312 
G-  If 

Copyright, 

By   E.    B.    TREAT,   N.  Y. 

1888-1894. 


PREFACE, 


The  affections  treated  of  in  the  following  pages  have 
ever  shown  a  decided  predilection  for  the  neurotic 
portion  of  our  population.  For  the  great  towns  of  the 
Atlantic  seaboard,  headaches  and  neuralgias  exhibit  a 
special  preference.  To  the  nervous  exhaustion  and 
strain  incident  to  the  irregular  mode  of  life  and  com- 
petition of  the  great  cities  are  due.  in  no  small  degree, 
these  head -pains  so  often  the  precursors  of  impending 
nervous  baDkruptcy.  The  same  causes,  in  conjunction 
with  one  of  the  most  trying  climates  to  be  found  in 
the  whole  world,  serve  also  to  give  rise  to  a  thousand 
aches  and  pains,  the  most  excruciating  of  which  are 
those  neuralgias  of  the  face  that  not  infrequently  drive 
the  victim  to  suicide  or  the  madhouse. 

For  several  years  past  I  have  devoted  much  time  to 
the  careful  study  of  these  prolific  sources  of  human 
misery.  I  have  not  done  this  in  a  spirit  of  mere  path- 
ological analysis;  but  I  can  truly  say  that  my  endeav- 
ors have  been  of  a  practical  kind,  every  thought  being 
directed  to  the  relief  and  cure  of  these  distressing 
affections. 

As  insomnia  is  one  of  the  most  constant  and  dis- 


8  PREFACE. 

tressing  accompaniments  of  pain,  I  have  added  a  chap- 
ter on  sleep  and  its  derangements,  which  I  trust  will 
lend  completeness  to  the  general  argument. 

When  to  personal  experience  I  add  the  fact,  that 
many  of  the  principles  herein  formulated  have  already 
been  extensively  promulgated  and  kindly  received  by 
my  professional  brethren  on  both  sides  of  the  Atlan- 
tic, I  may  perhaps  claim  extenuation  for  confideuce 
placed  in  my  own  undertakings. 

PEEFACE   TO   THE   SECOND   EDITION. 


The  kind  reception  which  the  first  edition  of  this 
work  received  at  the  hands  of  the  profession  has  been 
an  agreeable  surprise  to  the  author. 

As  regards  the  second  edition,  I  may  state*fchat  the 
value  of  the  work  has  been  materially  enhanced  by 
the  addition  of  an  appendix  on  the  relation  of  eye 
strain  to  headache,  contributed  by  my  distinguished 
friend,  Dr.  David  Webster,  of  New  York. 

Dr.  Webster's  reputation  as  an  accomplished  oph- 
thalmologist is  a  sufficient  guarantee  of  the  soundness 
of  his  opinions. 

J.  L.  Corning. 

New  York,  September  1st,  1889. 

PEEFACE   TO   THE   THIED   EDITION. 


To  this,  the  third  edition,  I  have  added  a  chapter 
on  the  "Localization  of  the  Action  of  Eemedies  upon 
the  Brain,"  which  I  trust  may  prove  suggestive  as 
well  as  useful. 

J.  L.  Corning. 

New  York,  January  1st,  1894. 


CONTENTS. 


PART  I.— HEADACHE. 
Pains  which  owe  their  Origin  to  Intra-Cranial  Causes. 

PAGE. 

I.  General  Considerations  on  the  Mechanism  of  Head- 
Pains  ;  Classification  of  Head-Pains 15 

II.  Anaemic  Headache 22 

III.  Hyperaamic  or  Congestive  Headache 26 

IV.  Nervous  or  Cerebral  Headache 38 

(a)  Cerebro-Hypersernic  Headache, 

(b)  Cerebro- Anaemic  Headache. 

V.  Toxic  Headache 44 

VI.  Sympathetic  Headache  ;  Bilious  Headache 47 

VII.  Organic  Headache,  or  that  which  is  dependent  upon 
profound  Changes  in  the  Constitution  of  the  Brain  or 

its  Membranes 52 

VIII.  Cases  Illustrative  of  Various  Phases  of  Headache    ...  56 

PART  II.— NEURALGIA. 
atns  which  owe  their  Origin  to  Extra-Cranial  Causes. 

IX.  General  Considerations 63 

X.  Classification    of    Neuralgia — (1)   Trigeminal    (Facial) 

Neuralgia 66 

XI.  Trigeminal  Neuralgia  continued.  Modification  in  the 
Symptoms  of  Facial  Neuralgia,  consequent  upon  the 
Restriction  of  the  Pain  to  one  or  more  Branches  of 
the  Nerve  ;  (2)  Cervico-Occipital  Neuralgia  ;  (3)  Cer- 

vico-Brachial  Neuralgia 69 

XH  Other  Varieties  of  Neuralgia 73 

(4)  Crural  Neuralgia. 

(5)  Lumbar  Neuralgia. 

(6)  Lumbo-Abdominal  Neuralgia. 

(7)  Dorso-Intei'costal  Neuralgia. 

(8)  Sciatic  Neuralgia. 


10  CONTENTS. 

(9)  Plantar  Neuralgia. 

(10)  Coccygodynia. 

(11)  Mastodynia. 

(12)  Muscular  Neuralgia.  PA6K 

XIII.  Causation 79 

XIV.  Diagnosis 82 

XV.  Pathology. . . . . 84 

XVI.  Prognosis 86 

XVII.  Treatment  in  General 88 

XVIII.  Local  Medication  of  Nerves,  Author's  Method 93 

XIX.  Local  Medication  of  Nerves  continued.  The  Prolonga- 
tion of  the  Local  Action  of  the  Remedy,  Author's 
Method ;  Cases  Illustrative  Nof  various  Phases  of 
Neuralgia  ;  The  Endermic  Use  of  Remedies  in  Neu- 
ralgia      97 

PART  III.— HISTORICAL. 

Consideration  of  Methods  of  Treatment 
heretofore  proposed. 

XX.  Methods  Involving  the  Use  of  Electricity 119 

XXI.  Electric  Methods  continued.  Simultaneous  Applica- 
tion of  Pressure  and  Galvanism 121 

XXII.  Narcotics  and  Sedatives 125 

XXIII.  Other    Remedies   which    have    been    Recommended ; 

Treatment  by  Freezing 132 

XXIV.  Surgical  Expedients 138 

XXV.  Some  Concluding  Observations  on  Rheumatic,  Osteal 

and  Periosteal  Head-Pains 140 

PART  IV.— IRRITATIVE  CONDITIONS  OF  THE  SPINE. 
XXVI.  Spinal  Irritation 145 

XXVII.  Spinal  Irritation  and  other  Painful  Symptoms  conse- 
quent upon  Slight  Local  Injury  or  General  Shock. .  169 

PART  V.— NORMAL  AND  MORBID  SLEEP. 

XXVIII.  Considerations  on  the  Physiology  of  Sleep 187 

XXIX.  Idiopathic  Insomnia 201 

XXX.  Secondary  Insomnia 206 

XXXI.  Considerations  on  Dreams 209 

XXXII.  The  Difference  between  Dreams  and  Waking  Thought.  215 

XXXm.    Morbid  Somnolence 219 

XXXIV.  General  Observations  on  the  Treatment  of  Insomnia 222 

XXXV.  Localization  of  the  Action  of  Remedies  upon  the  Brain .  .  228 

Appendix  :  Eye  Strain,  a  Cause  of  Headache 245 

Index 273 


PART  I. 


HEADACHE. 


PAINS  WHICH  OWE  THEIE  ORIGIN  TO  INTRA- 
CRANIAL CAUSES. 


CHAPTER   I. 

INTRODUCTORY  AND   RETROSPECTIVE. 

GENERAL  CONSIDERATIONS  ON  THE  MECHANISM   OF  HEAD- 
PAINS. — CLASSIFICATION  OF  HEAD -PAINS. 

Under  the  designation  of  headache,  I  propose  to 
consider  a  group  of  painful  sensations  located  in  the 
head,  and  usually  accompanied  by  more  or  less  sensory 
hyperesthesia,  mental  irritability  and  intellectual  pros- 
tration. 

As  the  clinical  significance  of  these  head -pains 
differs  more  or  less  widely,  it  is  not  surprising  that 
they  should  be  attributable  to  the  most  varied  causes. 
Thus  experience  has  shown  that  some  of  these  pain- 
ful sensations  about  the  head  may  be  due  to  extra- 
cranial causes,  such  as  osteosis  of  the  cranium  and 
dura  mater,  syphilitic  periostitis  of  the  cranium,  disease 
of  the  internal  ear,  neuralgic  and  rheumatic  affections 
of  the  scalp,  and  tumors  of  various  kinds.  On  the 
other  hand,  it  is  equally  certain  that  an  extensive 
category  of  headaches  is  directly  attributable  to  intra- 
cranial causes.  Under  the  latter  conditions  the  mental 
disturbances  are  decidedly  more  marked  than  when 
the  cause  of  the  pain  is  located  externally  to  the  cranial 
vault,  and  we  are  therefore  justified  in  speaking  of 
these  headaches  as  cerebral  or  brain-pains. 

Before  proceeding  to  discuss  the  symptomatology  of 
headaches,  it  will  be  well  to  consider  the  mechanism 


16  HEADACHE  AND  NEURALGIA. 

of  their  production,  as  classification  and  treatment  are 
alike  dependent  upon  some  conception,  however  im- 
perfect, of  the  pathological  features  involved. 

Of  the  purely  extra -cranial  pains  little  more  need  be 
said  than  that  they  are  evidently  one  and  all  attribut- 
able to  disturbances  in  the  molecular  conditions  of  the 
sensory  nerves  involved.  Whether  the  immediate 
source  of  such  disturbances  be  an  organic  lesion  (ex- 
ostosis, syphilitic  periostitis),  or  whether  it  consists  in 
some  occult  external  (rheumatic,  neuralgic)  element, 
matters  little  in  so  far  as  the  final  result  is  concerned. 

The  elucidation  of  the  mechanism  of  the  intra- 
cranial or  brain-pains  is,  however,  a  matter  of  far 
greater  difficulty.  In  considering  this  point,  Dr.  Sy- 
monds1  pertinently  observes  :  "Putting  aside  for  the 
present  any  reference  to  the  patient's  feelings,  what 
do  we  learn  from  anatomical  considerations  as  to  the 
probable  source  of  pain  within  the  cranium  when  the 
patient  is  the  subject  of  headache  ?  It  does  not  appear 
to  be  in  the  nervous  matter,  whether  vesicular  or  tub- 
ular, of  the  cerebral  hemispheres,  or  of  the  cerebellum. 
No  evidence  of  feeling  has  been  obtained  by  vivisectors 
till  they  approach  the  sensory  ganglia,  the  thalami 
optici  and  corpora  quadrigemina.  But  these  are  the 
centres  of  sensations  to  all  parts  of  the  body  as  well 
as  to  the  head.  All  analogy  must  further  look  to  the 
nerves  as  the  source  of  pain  (though  some  writers  are 
hardy  enough  to  doubt  the  necessity  of  nervous  mat- 
ter as  instrumental  in  sensation).  And  what  are  the 
nerves  ?  Numerous  as  are  the  nerves  which  come  out 
of  the  cranium,  there  are  on  a  superficial  view  very 
few  that  go  into  it.  A  branch  of  the  suboccipital  ac- 
companies the  vertebral  artery,  but  a  large  majority 

1  "  The  Gulstonian  Lectures  on  Headache,"  Medical  Times  and 
Gazette,"  1858. 


INTRODUCTORY   AND   RETROSPECTIVE.  17 

of  the  other  nerves,  destined  for  intra- cranial  purposes, 
are  derived  from  the  sympathetic. 

' '  These,  then,  are  the  nerves  which  are  of  chief  inter- 
est to  our  present  inquiry.  Nerves  of  this  class  accom- 
pany blood-vessels,  and  when  we  observe  the  large 
amount  of  these  vessels,  the  brain  and  its  membranes 
being  more  liberally  supplied  with  blood  than  any 
other  organ  (the  quantity  being  computed  as  one- fifth 
of  the  blood  of  the  whole  body),  we  might,  without 
searching  further,  feel  convinced  that  there  must  be  a 
corresponding  supply  of  ganglionic  nerves;  but  the 
minute  examination  of  modern  anatomists  has  tracked 
them  in  great  abundance." 

Discussing  the  same  point,  Memeyer1  observes 
that:  "Headache,  a  very  frequent  symptom  in  all 
cerebral  diseases,  is  very  difficult  to  explain;  we  do 
not  even  know  if  it  is  of  central  origin  (that  is,  if  it 
originates  in  the  parts  of  the  brain  where  irritation 
causes  symptoms  of  pain  after  the  insensible  greater 
hemispheres  have  been  removed),  or  whether,  as  I 
think  is  more  probable,  it  depends  on  irritation  of  the 
filaments  of  the  trigeminus  going  to  the  dura  mater. 
The  great  sensitiveness  to  impressions  on  the  senses 
depends  on  the  increase  of  excitability,  caused  by  the 
cerebral  hypersemia,  or  the  hyperesthesia  of  those 
portions  of  the  brain  through  which  peripheral  irrita- 
tions are  perceived.  The  patients  do  not  exactly  feel, 
see,  and  hear  more  sharply  than  ordinarily,  but  they 
are  annoyed  by  irritations  far  weaker  than  such  as 
usually  annoy  them.  Light  troubles  them;  a  slight 
sound  or  an  insignificant  irritation  of  the  nerves  of 
touch  excites  disagreeable  feelings.  Morbid  excitation 
(which  must  not  be  identified  with  increased  excitabil- 

1  "Memeyer's  Practical  Medicine,"  Vol.  II.,  p.  159,  quoted  by 
Day. 


18  HEADACHE  AND  NEURALGIA. 

ity)  of  the  same  central  parts  causes  the  dazzling  be- 
fore the  eye.  seeing  sparks,  roaring  and  buzzing  in  the 
ears,  the  sensation  of  formication,  or  of  undefined 
pain,  which  are  not  induced  by  peripheral  irritation." 

And  again,  Erb,1  referring  to  the  subject,  feels  com- 
pelled to  admit  that:  "Physiology  affords  little  aid 
in  determining  the  sensory  nerves  in  which  the  irrita- 
tion is  seated.  Experiments  upon  the  sensibility  of 
different  structures  in  the  interior  of  the  skull  have 
given  contradictory  results;  for  whilst  Ley  den,  Hitzig 
and  Ferrier  have  found  the  dura  mater  to  be  highly 
sensitive,  Pagenstecher  ascribes  a  very  low  degree  of 
sensibility  to  it,  and  Bartholow 2  who  experimented  on 
the  human  subject,  found  it  to  be  but  slightly  sensi- 
tive to  mechanical  stimuli.  The  greater  number  of 
experiments  seem  to  show  that  the  pia  mater  is  also 
not  very  sensitive,  and  the  same  may  be  said  in  regard 
to  the  greater  part  of  the  substance  of  the  hemispheres. 
When  Bartholow  pushed  his  needles  deep  into  the 
substance  of  the  cerebral  tissue,  pain  was  only  ex- 
perienced in  the  neck  after  they  had  been  pushed  in  to 
about  the  depth  of  the  great  ganglia  at  th3  base  of  the 
brain." 

"We  are  unable,  again,  from  physiological  consid- 
erations to  explain  why  headache  should  be  experi- 
enced when  the  intra-cranial  disease  is  situated  in  so 
many  different  parts  of  the  brain  or  of  its  membranes; 
we  must  either  admit  that  the  tissues,  which  under 
ordinary  circumstances  are  insensible  or  are  only  en- 
dowed with  a  low  degree  of  sensibility,  become  sensi- 
tive under  pathological   conditions,  and  give  rise  to 

1  "  Beard's  Archives  of  Electrology  and  Neurology,"  New  York, 
1874,  p.  68. 

2  "Diseases  of  the  Peripheral  Cerebro-Spinal  Nerves,"  article 
"Cephalalgia,"  "Ziemssen's  Cyclopaedia,"  p.  138  et  seq.,  187G. 


INTRODUCTORY   AND   RETROSPECTIVE.  10 

pain;  or  we  may  imagine  that  in  diseased  states  the 
influence  of  pressure  and  irritation  spreads  to  consid- 
erable distances,  involving  tissues  that  are  sensitive. 
The  dura  mater  may  undoubtedly  be  included  amongst 
such  sensitive  structures,  since  it  receives  sensory 
branches  from  the  trigeminus  and  vagus;  perhaps  the 
nerves  of  the  choroid  plexus,  which  Benedict '  has  re- 
cently described,  are  of  a  sensory  nature,  and  may  be 
answerable  for  the  '  internal '  headache  sometimes  com- 
plained of.  To  what  special  locality,  however,  we 
should  refer  these  '  nervous '  headaches,  is  still  unde- 
cided, and  we  can  only  offer  guesses  at  the  truth." 

The  most  recent  theory  regarding  the  mode  of  pro- 
duction of  pain  along  the  course  of  nerves,  as  in  neu- 
ralgia, is  that  promulgated  by  Prus.2  According  to 
this  writer  there  are  filaments  in  the  sheaths  of  nerve- 
truuks,  the  irritation  of  which  gives  rise  to  the  painful 
points  found  in  neuralgic  affections.  These  filaments, 
the  presence  of  which  was  made  known  by  careful 
microscopical  examination,  have  received  the  some- 
what ponderous  appellation  of  nervi  nervorum  peri- 
phericorum.  What  part  these  structures  are  destined 
to  play  in  the  pathology  of  the  future,  experience 
alone  can  show. 

As  to  the  opinions  entertained  by  myself  with  regard 
to  the  precise  location  and  mechanism  of  these  painful 
intra-cranial  sensations,  I  can  only  agree  with  Nie- 
meyer  and  Erb  that  the  ground  we  tread  upon  is  un- 
certain; and  that,  as  far  as  deriving  definite  conclu- 
sions from  anatomy  and  physiology  is  concerned,  we 
are  left  somewhat  in  the  dark.  This  much  I  will  ven- 
ture to  affirm,  however,  that  inasmuch  as  psychical 

1  Virchow's  Arch,  band  59 

2  Archives  Slaves  de  Biologie,  IV.,  2  Sept,  1887.  See  also  Brain, 
Vol.  X.,  p.  557. 


20  HEADACHE  AND  NEURALGIA. 

disturbances  assuming  the  form  of  grief,  worry  and 
apprehension  are  of  themselves  quite  capable  of  evok- 
ing severe  intra-cranial  pain,  the  latter  is  certainly  in 
some  manner  due  to  cerebral  agency.  That  such  a 
connection  must  of  necessity  exist,  is  shown  bv  the 
fact  that  when  the  disturbing  psychical  element  is  re- 
moved the  pain  frequently  ceases  instantaneously.  To 
be  sure  such  facts  do  not  adequately  explain  the  oc- 
currence of  the  form  of  headache  due  to  a  variety  of 
purely  physical  causes,  but  they  are  nevertheless 
eminently  suggestive,  since  they  are  clearly  instances 
of  headaches  evoked  by  forces  operating  solely  by  and 
through  the  brain. 

On  a  superficial  view,  it  would  appear,  then,  that 
we  meet  with  overwhelming  obstacles  on  the  very 
threshold  of  our  investigation  into  the  origin  of  these 
pains  within  the  skull.  The  problem  is,  however, 
from  a  clinical  standpoint  at  least,  not  so  discouraging 
as  it  would  appear  at  first  sight;  for,  owing  to  the  fact 
that  we  are  acquainted  with  a  considerable  number  of 
the  factors  concerned  in  the  evolution  of  these  pains, 
we  are  able  to  apply  such  knowledge  to  the  practical 
ends  of  treatment.  Again,  although  for  the  same  rea- 
son, it  is  impossible  to  arrange  the  numerous  varieties 
of  headache  upon  the  basis  of  their  respective  and 
ultimate  pathological  terms,  we  are  at  least  able  to 
classify  the  prominent  forms  of  intra-cranial  pain  in 
accordance  with  their  more  obvious  pathogenesis.  Fol- 
lowing this  method,  we  may  classify  the  various  forms 
of  headache  as  follows: 

INTRA-CRANIAL  HEADACHE.1 

(1.)  Anaemic  Headache. 

(2.)  Hypereemic  or  Congestive  Headache. 

1  Nos.  3  and  5  are  commonly  known  as  "  Sick  Headache." 


INTRODUCTORY   AND   RETROSPECTIVE.  21 

(3.)  Nervous  or  Cerebral  Headache. 

(a)  Cerebro-Hypersemic  Headache. 

(b)  Cerebro- Anaemic  Headache. 
(4.)  Toxic  Headache. 

(5.)  Sympathetic  Headache.     Bilious  Headache,  &c. 
(6.)  Headache   dependent  upon  organic  disease   of 
the  brain  or  its  appendices. 

EXTRACRANIAL  HEADACHE. 

(1.)  Neuralgia,  General  Considerations  on, 

(a)  Rheumatic  Headache. 
(2.)  Osteal  and  Periosteal  Headache, 


CHAPTER    II. 

ANJEMIC    HEADACHE. 

The  proximate  cause  of  this  form  of  head-pain  is 
deficiency  of  blood  within  the  cranial  cavity.  It  is  an 
almost  invariable  attendant  on  general  anaemia  and 
chlorosis,  and  consequently  young  women  of  feeble 
constitution  are  particularly  liable  to  its  attacks.  The 
affection  is  not,  however,  restricted  to  any  particular 
form  of  weakness,  but,  on  the  contrary,  it  is  a  common 
attendant  on  all  forms  of  debility.  Uterine  hemor- 
rhage, epistaxis,  haemorrhoids,  mal-nutrition,  chronic 
diarrhoea  and  over  exertion  both  mental  and  physical 
may  produce  it.  Masturbation  in  both  sexes  may  give 
rise  to  it;  and  excessive  indulgence  in  strong  tobacco 
may  cause  it.  One  of  the  most  prolific  predisposing 
causes  of  the  affection  is  morbid  sexualism,  as  I  have 
frequently  observed  both  in  married  and  single  indivi- 
duals. 

Symptoms. — Sometimes  those  affected  by  this  variety 
of  headache  complain  of  a  sensation  of  tightness  about 
the  forehead,  as  though  the  head  were  encircled  by  a 
band.  Sometimes  again  the  pain  is  more  restricted  in 
character  and  manifests  itself  in  clawing  sensations, 
which  are  particularly  well  marked  at  the  vertex. 
Whatever  the  location  of  the  pain  may  be,  it  is 
almost  invariably  less  pronounced  when  the  subject 
is  in  the  recumbent  position  than  when  the  body  is 
maintained  in  an  erect  attitude.  Less  pain  is  there- 
fore felt  during  the  latter  part  of  the  night  and  early 


ANEMIC    HEADACHE.  23 

morning  than  during  the  day.  In  the  more  exquisite 
cases  the  simple  act  of  rising  is  sufficient  to  cause 
vertigo  and  even  syncope;  indeed  symptoms  of  giddi- 
ness and  weakness  in  the  lower  extremities  are  almost 
constant  accompaniments  of  this  form  of  headache. 

Sleep  is  also  more  or  less  affected,  though  during  the 
day  the  subject  is  frequently  beset  by  a  morbid  drow- 
siness which  he  endeavors  to  exorcise  by  the  copious 
use  of  stimulants.  The  energy  of  the  heart's  action  is 
reduced;  and  in  very  severe  cases  the  venous  murmur 
may  be  present  in  the  neck  as  well  as  oedema  of  the 
ankles  and  of  the  legs.  The  latter  condition  is  for- 
tunately rare.  Palpitations,  extreme  fatigue  upon  the 
slightest  exertion  and  attacks  of  sudden  fainting  are 
frequently  met  with.  The  surface  of  the  body  and 
particularly  the  face  are  cold  to  the  touch,  and  the 
countenance  has  a  peculiarly  blanched  and  waxy  ap- 
pearance. A  morbid  susceptibility  to  sensory  impres- 
sions, particularly  of  light  and  sound,  is  present  in 
most  cases.  The  sensitiveness  to  light  is  often  so  great 
that  the  subject  insists  upon  remaining  in  a  darkened 
room  during  the  day,  while  an  artificial  light  of  any 
kind  is  absolutely  unendurable.  The  susceptibility  to 
acoustic  impressions  of  all  kinds  may  also  be  abnor- 
mally increased,  so  that  such  trivial  occurrences  as  the 
squeaking  of  a  door,  the  rumbling  of  a  cart,  or  ordin- 
ary conversation  are  absolutely  unendurable. 

The  peculiar  flaccid  state  of  the  heart,  which  is  so 
characteristic  of  this  condition,  has  been  graphically 
alluded  to  by  Dupuytren  as  "  relachement  du  cceur. " 

A  symptom  of  considerable  diagnostic  importance 
is  the  feeble  pulsation  of  the  carotids — a  phenomenon 
which  is  never  absent  in  pronounced  cases.  Very 
slight  pressure  upon  these  arteries  is  sufficient,  where 
the  anaemia  is  severe,  to  provoke  an  immediate  attack 


24  HEADACHE  AND  NEURALGIA. 

of  syncope.  I  first  called  attention  to  this  symptom 
some  time  ago,  and  I  have  since  had  occasion  to 
verify  the  assertions  then  made  over  and  over  again. 
The  surface  thermometer  when  properly  applied 
over  the  vertex  shows  a  considerable  diminution  in 
temperature  as  compared  with  the  rest  of  the  body. 
Again,  persistent  drooping  of  the  eyelids  is  an  almost 
constant  symptom  in  this  form  of  headache,  and  one 
of  considerable  diagnostic  value,  from  the  fact  that 
the  phenomenon  may  be  produced  experimentally  by 
the  appropriate  application  of  compression  to  the  caro- 
tids, as  I  have  frequently  demonstrated.1 

Treatment. — The  temporary  relief  of  this  form  of 
headache  is  a  matter  of  no  great  difficulty,  especially 
if  the  cerebral  anaemia  is  due  rather  to  vaso  motor 
than  to  general  causes. 

The  inhalation  of  a  few  drops  of  the  nitrate  of  amyl 
is  often  followed  by  immediate  relief,  but  the  latter  is 
usually  of  only  temporary  duration,  unless  special 
means  be  adopted  to  perpetuate  the  good  effects  of  the 
remedy.  This  object  may  be  accomplished  in  a  variety 
of  ways:  the  inhalations  of  the  nitrate  may  be  repeated 
several  times  a  day;  the  patient  may  be  placed  upon  a 
sofa  or  bed,  the  foot  of  which  is  elevated  by  means  of 
blocks  of  wood;  alcohol  may  be  given  in  frequent 
doses;  the  salts  of  iron  and  quinine  may  be  adminis- 
tered, or  opium  may  be  given  in  small  doses,  a  mode 
of  treatment  which  has  yielded  good  results  in  the 
hands  of  various  practitioners  in  certain  cases. 

Of  all  the  remedies  above  enumerated  pre-eminent 
importance  must  be  assigned  to  alcohol;  when  taken 
in  moderate  quantities  it  increases  the  energy  of  the 
heart's  action  and  at  the  same  time  causes  dilatation 

1  "Brain  Rest,"  by  J.  Leonard  Corning,  Gr.  P.  Putnam's  Sons. 
Also  the  various  papers  and  articles  alluded  to  in  this  work. 


ANEMIC    HEADACHE.  25 

of  the  minute  blood-vessels  of  the  brain.  It  should 
never,  however,  be  given  in  very  large  quantities,  since 
when  thus  administered  it  causes  depression  of  the 
nervous  centres,  besides  exercising  the  most  prejudicial 
effects  upon  the  digestive  and  assimilative  systems. 

McLane  Hamilton  has  found  that  the  inhalation  of 
nitrous  oxide  is  of  great  benefit  in  anaemic  headache. 
The  ordinary  apparatus  used  by  dentists  was  employed 
in  administering  the  gas. 

The  importance  of  maintaining  a  horizontal  position, 
especially  during  the  early  stages  of  the  affection,  can 
hardly  be  overestimated;  and  the  benefits  thence  to  be 
derived  may  be  greatly  enhanced  by  elevating  the 
lower  extremities  by  means  of  cushions,  or  preferably 
by  raising  the  foot  of  the  bed  or  lounge  by  means  of 
blocks  placed  beneath  the  feet. 

After  all  has  been  said,  however,  with  regard  to  re- 
medies, it  must  be  admitted  that  the  ultimate  reliance 
of  the  physician  consists  in  enhancing  the  powers  of 
the  apparatus  of  digestion  and  absorption.  Cod- liver 
oil,  rare  beef-steaks  and  mutton-chops  should  occupy 
a  prominent  place  in  the  dietary;  while  milk  and  eggs 
may  be  given  ad  libitum,  where  the  digestive  powers 
are  not  seriously  impaired. 

As  a  matter  of  course,  if  the  anaemia  be  due  to  the 
presence  of  some  obviously  morbid  element,  the  latter 
should  be  gotten  rid  of  as  soon  as  possible.  If  the  di- 
gestive apparatus  is  impaired  it  should  be  put  in  good 
condition  as  soon  as  possible;  if  there  is  hemorrhage 
from  the  uterus  or  any  other  portion  of  the  body  it 
should  be  arrested,  and  in  short  from  whatever  source 
the  debilitating  influences  emanate,  they  should  be 
neutralized  or  removed  as  expeditiously  as  circum- 
stances will  admit. 


CHAPTER   III. 

HYPERJEMIC   OR   CONGESTIVE   HEADACHE. 

Symptomatology. — In  this  form  of  head-pain  the 
subject  complains  of  a  severe  tensive  pain,  and  at  the 
same  time  experiences  a  sensation  of  fullness,  as 
though  the  cranium  were  too  small  for  its  contents. 
As  a  rule  the  painful  sensations  are  not  circumscribed 
in  character,  but  are  distributed  throughout  the  entire 
extent  of  the  cranium.  The  pain  is  constant,  and  is 
augmented  by  assuming  the  recumbent  posture;  conse- 
quently sleep  is  more  or  less  profoundly  affected.  All 
forms  of  mental  or  physical  exertion  are  followed  by 
exacerbations  of  pain  accompanied  by  more  or  less 
vertigo.  The  subject  is  extremely  irritable  and  aroused 
to  inordinate  passion  by  the  most  trivial  circumstances; 
he  is  pessimistic,  depressed  and  lachrymose,  and  in- 
clined to  find  fault  with  all  about  him.  Sensory  dis- 
turbances are  also  more  or  less  common,  and  may  con- 
sist in  functional  exaltation  or  depression. 

Sometimes  the  action  of  the  heart  is  inordinately  in- 
creased in  strength  and  considerably  accelerated,  so 
that  the  patient  complains  of  throbbing  in  the  tem- 
poral and  carotid  arteries,  which  in  some  cases  is  so 
violent  as  to  be  easily  discovered  with  the  naked  eye. 

There  is  also  a  well-marked  increase  in  temperature, 
particularly  above  the  vertex,  and  the  face  is  suffused 
to  such  a  degree  as  to  present  a  livid,  coppery  appear- 
ance. 

Causation. — The  immediate  cause  of  the  above 
group  of  symptoms  is  an  increase  in  the  arterial  blood- 


CONGESTIVE   HEADACHE.  27 

tension,  accompanied  by  more  or  less  relaxation  on  the 
part  of  the  cerebral  capillaries.  A  somewhat  similar 
series  of  phenomena  may.  however,  be  evoked  by  dis- 
tension of  the  intra-cranial  veins  consequent  upon 
some  form  of  obstruction  to  the  flow  of  blood  in  the 
same  (passive  congestion).  When  the  impediment  is 
serious,  coma  may  be  induced.  Vaso-motor  insuffici- 
ency, especially  that  affecting  the  intra-cranial  circula- 
tion, is  a  prolific  cause  of  the  congestive  form  of  head- 
ache ;  it  may  result  from  the  most  varied  causes,  and 
is  especially  prone  to  occur  as  the  consequence  of 
excessive  sexualism  and  the  protracted  abuse  of  alco- 
holic stimulants.  To  enumerate  all  the  pathological 
conditions  which  may  give  rise  to  this  form  of  head- 
ache would,  however,  involve  the  recapitulation  of  a 
considerable  segment  of  special  and  general  pathology, 
and  would,  of  course,  be  supererogatory  in  a  work  of 
this  kind. 

Treatment. — Without  doubt  the  most  expeditious 
mode  of  affording  relief  in  uncomplicated  cases  of  con- 
gestive headache —those  which  are  attributable  to 
abnormal  heart  or  vaso-motor  conditions,  or  both — 
consists  in  the  skillful  application  of  compression  to 
the  common  carotid  arteries  '  by  means  of  appropriate 
instruments.     Electro-compression 2  also  yields  excel- 

1  "  Prolonged  Instrumental  Compression  of  the  Primitive  Car- 
otid Artery  as  a  Therapeutic  Agent,"  by  J.  Leonard  Corning, 
M.D.,  "New  York  Medical  Record"  for  Feb.  18th,  1882.  Also  article 
in  "Philadelphia  Medical  News,"  for  June  17th,  1882;  this  arti- 
cle may  also  be  found  in  the  "  American  Journal  of  Neurology 
and  Psychiatry,"  1882.  See  also,  "  Carotid  Compression,"  Anson 
D.  F.  Randolph  &  Co.,  New  York,  1882,  Ibid.  "Brain  Rest:" 
A  Disquisition  on  the  Curative  Properties  of  Prolonged  Sleep, 
by  J.  Leonard  Corning;  M.D.,  G.  P.  Putnam's  Sons,  New  York, 
Second  Edition,  1886. 

2  For  the  original  paper  on  the  combined  application  of  com- 


28  HEADACHE  AND  NEURALGIA. 

lent  results,  especially  in  those  cases  where  the  adipose 
covering  of  the  neck  is  of  such  thickness  as  to  render 
the  application  of  strong  pressure  without  implication 
of  the  jugular  difficult  or  practically  impossible. 

Of  the  two  procedures  electro-compression  will  on 
the  whole  be  found  most  effective  and  universally  ap- 
plicable. As  some  of  my  readers  may  not  be  familiar 
with  the  rules  which  I  have  elsewhere  given  for  carry- 
ing out  this  mode  of  treatment,  I  will  give  the  salient 
points  involved. 

MODE  OF  EXECUTING  ELECTRO-COMPRESSION. 

For  applications  of  short  duration,  and  these  are  the 
most  uniformly  useful  in  the  treatment  of  congestive 
varieties  of  headache,  I  have  found  the  following  device 
convenient:  It  consists  in  the  first  place  of  two  curved 
metallic  branches,  resembling  in  shape  an  ordinary 
horse  shoe.  To  each  of  the  extremities  of  these 
branches  is  attached  a  small  sponge  electrode.  These 
electrodes  are  insulated  by  means  of  hard  rubber 
plates.  To  each  of  the  electrodes  is  attached  a  con- 
ducting cord.  These  cords  unite  in  one  common  stem, 
which  being  secured  to  the  binding  post  of  a  galvanic 
battery  renders  the  polarity  of  the  two  sponge  elec- 
trodes the  same.     (Fig.  1.) 

It  is  possible  by  means  of  a  screw  provided  with  a 
detachable  key  to  place  the  electrodes  at  an  angle. 
The  object  of  this  device  is  to  enable  the  operator  to 
exercise  pressure  upon  the  carotids  in  an  oblique  direc- 
tion, so  as  to  press  them  away  from  the  jugular  veins 

pression  and  electricity,  see  "  Electrization  of  the  Sympathetic 
and  Pneumogastric  Nerves,with  Simultaneous  Bilateral  Compres- 
sion of  the  Carotids,"  by  J.  Leonard  Corning,  M.D.,  "  The  New 
York  Medical  Journal  "  for  February  23d,  1884 


ELECTRO-COMPRESSION. 


29 


Fig.  1. — Author's  Electro-Compressor. — a  a',  insulated  sponge  electrodes  in  con- 
nection with  the  bifurcated  conducting  wire  6;  c,  milled  wheel,  the  rotation  which 
causes  the  screw  d  to  act  upon  the  armatures  e  e',  thus  enabling  the  operator  to  ex- 
pand or  approximate  the  latter  at  will. 


30 


HEADACHE  AND  NEURALGIA. 


in  the  direction  of  the  spinal  column.  By  this  means 
it  is  possible  to  reduce  venous  pressure  to  a  minimum. 
Again,  the  branches  themselves  may  be  extended  or 
approximated  at  will,  an  advantage  obtained  by  the 
use  of  the  Archimedean  screw.  An  exceedingly  fine 
adjustment  is  thus  rendered  possible. 

The  method  of  employing  the  instrument  just  de- 


Fig.  2.— Showing  Mode  op  Applying  Electro-compression.  A,  differential  calo- 
rimeter, connected  with  the  thermo-electric  piles  d  d,  by  means  of  the  conducting 
wires  e  e'.  B,  galvanic  battery  connected  with  the  electro  compressor  C  by  means 
of  the  bifurcated  conducting  wire  /.  The  electrode  at  the  extremity  of  the  other 
conducting  wire  /'  is  placed  on  the  neck. 

cribed  is  exceedingly  simple.  The  patient,  if  in  bed, 
is  placed  in  a  horizontal  and  semi-dorsal  position,  with 
the  head  supported  by  a  cushion  beneath  the  neck,  in 
such  a  manner  as  to  allow  the  head  to  fall  slightly 
backward,  while  the  cervical  vertebrae  are  protruded 
anteriorly  (Fig.  2).     The  operator  then  takes  his  place 


ELECTRO-COMPRESSION.  3i 

by  the  bedside,  his  left  side  being  turned  toward  the 
patient.  Then,  having  with  the  index-finger  and 
thumb  ascertained  by  careful  exploration  the  exact 
position  of  the  carotids,  he  proceeds,  after  accurately 
adjusting  the  armatures,  to  apply  the  instrument  in 
such  wise  that  the  electrodes  will  press  the  arteries 
away  from  the  pneumogastric  nerve  and  jugular  vein 
in  the  direction  of  the  spinal  column. 

In  applying  the  instrument  it  should  be  held  in  the 
right  hand,  the  handle  forming  a  perpendicular  to 
the  arteries.  By  pressing  the  left  hand  firmly  against 
the  posterior  portion  of  the  neck,  the  operator  is 
enabled  to  execute  any  counter-pressure  which  may 
be  required,  and  at  the  same  time  to  contribute  to  the 
support  of  the  head  in  the  desired  position.  Compres- 
sion should,  however,  never  be  carried  so  far  as  to 
cause  entire  closure  of  the  lumina  of  both  arteries ; 
such  a  procedure  may  cause  convulsions,  as  the  anas- 
tomotic facilities  at  the  circle  of  Willis  are  usually 
unequal  to  these  unwonted  circulatory  exigencies. 
This  contingency  is,  however,  not  liable  to  arise,  as 
the  degree  of  pulsation  in  the  temporal  arteries  affords 
reliable  information  as  to  the  extent  of  the  circulatory 
obstruction. 

"When  the  instrument  has  been  properly  adjusted, 
an  assistant  applies  the  disengaged  electrode  (usually 
the  positive)  over  the  posterior  aspect  of  the  cervical 
vertebrae. 

All  being  in  readiness,  the  strength  of  the  battery  is 
gradually  increased. 

It  is  impossible  to  determine  in  advance  how  many 
cells  may  be  required,  as  this  will  depend  greatly 
upon  the  strength  of  the  battery,  the  thickness  of  the 
cervical  adipose  tissue,  and  the  degree  of  compression 
employed.     The  greater  the  amount  of  compression  the 


32  HEADACHE  AND  NEURALGIA. 

less  the  strength  of  the  current  should  be,  and  vice 
versa. 

Care  should  be  exercised  to  avoid  dizziness  or  syn- 
cope, and  the  strength  of  the  current  and  degree  of 
pressure  should  at  all  times  be  regulated  with  the  ut- 
most nicety.  Sudden  variations  in  either  of  these 
factors  are  to  be  carefuhy  avoided.  By  this  mode  of 
treatment  we  accomplish  a  threefold  end:  (1)  Dimi- 
nution of  the  amount  and  pressure  of  the  cortical 
bloodstream;  (2)  Contraction  of  the  cerebral  capil- 
laries; and  (3)  Reduction  of  the  intensity  of  the 
heart's  action  (when  currents  of  considerable  strength 
are  employed). 

I  have  frequently  caused  entire  cessation  of  the  con- 
gestive form  of  head-pain  in  the  course  of  from  fiv3  to 
eight  minutes  by  the  use  of  this  method  of  treatment. 

Only  secondary  in  importance  to  the  above  method 
of  treatment  is  the  application  of  cold  to  the  head. 
This  may  be  done  by  means  of  the  ice-bags  in  general 
use,  or  better  still  by  the  employment  of  the  apparatus 
recommended  by  Mr.  Joseph  Leiter,  Dr.  Knowsley 
Thornton  and  others.  This  appliance  consists  in  a 
series  of  india-rubber  spirals,  which  are  wound  around 
the  head  in  the  form  of  a  cap.  By  passing  a  stream  of 
cold  water  through  these  spirals  it  is  possible  to  main- 
tain the  water  in  them  at  an  exceedingly  low  tempera- 
ture. This  method  of  treatment  has  been  extensively 
employed,  I  believe,  by  Mr.  Spencer  Wells  of  London, 
especially  after  the  operation  of  ovariotomy. 

This  ice- water  cap  may  be  employed  with  increased 
benefit  in  conjunction  with  hot  water  both  to  the  feet 
and  calves;  the  effects  thus  attainable  being  striking. 

Hot  baths  to  the  entire  bod)7  ranging  in  temperature 
from  103°  to  110°  may  be  prescribed  with  advantage, 
where  other  means  of  treatment  are  not  accessible. 


BATHS. 


33 


Baths  of  this  character  affect  the  central  nervous 
system  to  a  much  greater  extent,  and  in  a  shorter  space 
of  time  than  warm  baths.  The  skin  becomes  rapidly 
congested ;  respiration  is  increased  and  inspiration 
becomes  deeper.     As  a  rule  these  baths  are  followed 


Fig.  3.— Mode  of  Applying  Ice-water  Cap.    (After  Leiter.) 

by  profuse  perspiration,  and  their  derivative  action 
upon  the  engorged  cerebral  centres  is  not  to  be  over- 
estimated. 

The  hot-air  or  Turkish  bath  has  a  wide  application 
in  the  treatment  of  the  congestive  form  of  headache; 
3 


34  HEADACHE  AND  NEURALGIA. 

and  I  have  no  hesitancy  in  recommending  its  employ- 
ment in  this  connection,  though  fully  aware  that  a 
prejudice  exists  against  the  use  of  hot  haths  in  brain 
affections.  The  sojourn  of  the  patient  in  the  hot-room 
should  not,  however,  be  of  too  long  duration  ;  twenty 
or  thirty  minutes  are  quite  enough.  When  possible, 
the  subsequent  application  of  the  douche  should  be  in 
the  form  of  the  hot -water  stream,  as  recommended  by 
certain  French  physicians,  in  order  to  redden  the  skin, 
especially  about  the  back  and  lower  limbs.  As  soon 
as  this  operation  is  completed  the  patient  should  be 
put  to  bed  and  wrapped  in  warm  blankets. 

A  most  excellent  expedient,  in  severe  cases,  is  the 
application  of  a  leech  at  each  side  of  the  septum  narium, 
about  half  an  inch  above  the  nares.  This  may  easily 
be  accomplished  by  the  aid  of  a  curved  leech  glass. 
The  hemorrhage  which  follows  is  sometimes  profuse, 
but  may  be  arrested  by  the  application  of  a  tampon  of 
styptic  cotton  on  each  side  of  the  septum.  In  order 
to  increase  the  bleeding,  it  is  only  necessary  to  hold 
the  head  over  a  bowl  of  hot  water. 

Should  the  hemorrhage  from  the  mucous  membrane 
prove  obstinate,  the  application  of  a  solid  point  of 
nitrate  of  silver  over  the  bite  may  be  resorted  to.  It 
is  hardly  necessary  to  add  that,  in  the  application 
of  leeches  to  the  septum,  care  should  be  taken  to 
prevent  the  passage  of  the  animals  into  the  nasal 
cavity.  This  may  be  accomplished  by  previously 
plugging  the  nostrils  with  cotton  wool.  In  order  to 
avoid  the  employment  of  leeches,  I  have  had  con- 
structed an  apparatus,  by  means  of  which  artificial 
epistaxis  may  be  produced  in  a  satisfactory  manner, 
and  without  the  slightest  possibility  of  accident. 

It  consists,  in  the  first  place,  of  the  jar  (e),  which  is 
connected  with  the  air  pump  (h),  by  means  of  which 


ARTIFICIAL   EPISTAXIS. 


35 


it  is  possible  to  cause  a  vacuum  in  the  vessel  (e).  The 
gauge  (/)  registers  the  degree  of  approach  to  a  vacuum. 
An  india-rubber  tube  connects  the  jar  with  the  small 
bottle  (c),  which  is  provided  with  a  scale.  A  bifur- 
cated tube  (b)  connects  the  bottle  with  the  two  small 
cupping  bowls  (a  a)  ;  the  latter  are  sufficiently  minute 
to  admit  of  their  introduction  into  each  nostril  respec- 
tively. As  they  are  provided  with  india-rubber  gar- 
nitures, it  is  possible  to  adapt  them  accurately  to  the 
sides  of  the  septum. 


Fig.  4.— Author's  Apparatus  for  Artificial  Epistaxis. 


The  mode  of  employment  is  simple  enough.  The 
cupping  bowls  having  been  introduced,  a  small 
scalpel  is  inserted  in  turn  beneath  the  edge  of  each, 
by  means  of  which  the  mucous  membrane  of  the 
septum  is  slightly  scarified.  The  cupping  bowls 
are  then  connected  with  the  vacuum  jar  and  with 
the  bottle  by  opening  the  appropriate  stop -cocks. 
These  valves  (i,  i,  i,  i)  require  no  explanation,  as  their 
function  is  self-evident  from  the  situation  which  they 
occupy.     Short  segments  of  glass  tubing,  inserted  in 


36  HEADACHE  AND  NEURALGIA. 

the  india-rubber  pipes  below  the  cupping  bowls,  enable 
the  operator  to  observe  whether  the  blood  is  flowing 
properly,  or  whether  further  scarification  is  necessary. 
As  the  blood  flows  into  the  graduated  bottle  already 
described,  it  is  possible  to  determine  with  accuracy 
the  amount  removed. 

Blisters  to  the  nape  of  the  neck  and  sinapisms  to  the 
calves  of  the  legs  have  been  highly  praised  by  some  as 
adjuncts  to  other  modes  of  treatment;  while  the  scari- 
fication of  the  nape  of  the  neck  has  also  found  advo- 
cates. 

The  application  of  the  constant  galvanic  current  to 
the  head  is  a  useful  expedient  in  some  cases,  but  too 
much  reliance  should  not  be  placed  upon  it. 

On  the  other  hand,  dry-cupping  when  extensively 
practised  is  sometimes  attended  with  happy  results,  es- 
pecially in  the  milder  forms  of  congestion.  A  very  good 
method  for  carrying  out  this  form  of  treatment  is  to 
smear  the  posterior  portion  of  the  neck  and  the  back 
throughout  its  entire  extent  with  spermacetti  ointment; 
the  exhaust  glass  (which  should  be  large)  is  then  re- 
peatedly applied  and  voided  by  means  of  the  air  pump. 
This  procedure  is  repeated  until  the  entire  back  be- 
comes livid.  It  is  evident  that  such  a  degree  of  super- 
ficial congestion  must  exercise  no  little  derivative 
action  upon  the  deeply  seated  tissues;  and  indeed  the 
results  obtained  in  cerebral  and  other  forms  of  conges- 
tion are  sometimes  all  that  could  be  desired.  Where 
the  engorgement  is  very  considerable,  however,  it  is 
usually  necessary  to  resort  to  some  one  of  the  more 
powerful  remedies  already  referred  to.  Venesection, 
to  which  resort  was  had  by  the  older  physicians  in 
congestion  and  other  forms  of  headache,  can  only  meet 
with  unqualified  condemnation  by  the  modern  neuro 
pathologist  as  at  once  a  supererogatory  and  even  dan- 


ELECTRO -COMPRESSION.  37 

gerous  procedure.  Local  depletion  by  epistaxis— the 
most  direct  mode  of  affecting  the  cerebral  circulation  by 
blood-letting, — or  compression  of  the  carotids  by  means 
of  appropriately  constructed  instruments,  are  certainly 
far  more  direct  in  their  effects  than  general  depletion, 
and  at  the  same  time  quite  devoid  of  danger  or  dis- 
agreeable consequences  of  any  kind. 


CHAPTER   IV. 

NERVOUS   OR   CEREBRAL  HEADACHE. 

Under  this  designation  I  propose  to  consider  that 
variety  of  headache  which,  in  its  typical  form,  is  char- 
acterized by  the  absence  of  all  circulatory  derange- 
ments and  neuralgic  symptoms.  The  most  logical 
supposition  relative  to  the  pathology  of  this  form  of 
headache  is  that  which  ascribes  the  painful  phenomena 
to  certain  subtle  morbid  changes  originating  in  the 
substance  of  the  nervous  centres  themselves.  To  be 
sure,  we  have  no  further  proof  of  the  truth  of  this  hy- 
pothesis than  that  afforded  by  the  fact,  that  this 
variety  of  headache  may  be  readily  evoked  by  pro- 
found emotional  disturbances  —  factors  which  appeal 
directly  to  the  psychical  centres — in  the  absence  of  all 
purely  physical  causes,  such  as  neuralgia  or  derange- 
ments of  the  intra-cranial  circulation.  Neither  this 
nor  any  other  theory  relative  to  the  nature  of  the  affec- 
tion can,  however,  be  accepted  as  in  any  sense  final. 

Unlike  the  anaemic  and  hypersemic  varieties  of  head- 
ache, the  form  of  the  affection  which  we  are  consider- 
ing is  not  readily  amenable  to  experimental  inves- 
tigation, and  hence,  as  already  intimated,  we  are 
reduced  to  the  necessity  of  forming  our  conclusions 
from  data  which,  to  say  the  least,  are  insufficient. 
Pending  more  exact  knowledge,  however,  the  theory 
which  ascribes  the  phenomena  of  the  affection  to 
some  subtle  disturbance  in  the  cerebral  substance  may 
be  accepted;  and  it  may  also  be  added  that  this  hypo- 


NERVOUS   HEADACHE.  39 

thesis  will  be  found  to  lead  to  a  thoroughly  enlight- 
ened and  effective  practice. 

Symptoms. — In  many  persons  the  onset  of  the  head- 
ache is  marked  by  the  occurrence  of  digestive  derange- 
ments in  the  form  of  eructations,  flatulency,  or  consti- 
pation. There  is  always  more  or  less  malaise  and 
mental  irritability  in  the  beginning,  and  the  latter 
symptoms  usually  become  greatly  exaggerated  in  the 
course  of  a  few  hours. 

The  pain  begins  in  some  persons  with  a  certain 
amount  of  visual  disturbance;  the  sight  becomes 
clouded,  and  at  the  same  time  an  acute  pain  is  felt  in 
the  corresponding  temple.  With  these  symptoms  the 
patient  usually  experiences  more  or  less  nausea,  con- 
fusion of  ideas  and  vertigo  ;  while,  at  the  same  time, 
his  thoughts  become  concentrated  on  his  real  or  antici- 
pated misfortunes,  with  the  result  of  greatly  augment- 
ing the  intensity  of  the  head-pains.  Sometimes  the 
pain  is  felt  in  the  vertex,  forehead  or  occiput ;  but  in 
a  considerable  percentage  of  cases,  it  becomes  located 
in  one  temple,  in  one-half  of  the  head,  or  in  one  eye  ; 
so  that  the  supposition  may  be  formed  that  the  nerves 
of  the  head  are  implicated,  as  in  neuralgia. 

There  is  also  more  or  less  sensitiveness  to  sensory 
impressions  of  all  kinds  ;  the  patient  shuns  the  light 
and  stops  her  ears  with  pledgets  of  cotton,  or  with  her 
fingers,  in  order  to  keep  out  the  din  of  the  house  and 
street. 

Sometimes  the  subject  complains  of  feeling  as 
though  her  eye  were  being  forced  out  of  the  socket,  or 
as  though  the  side  of  her  nose  were  being  burned  with 
a  hot  iron. 

I  have  already  mentioned  the  cerebro-hypersemic  and 
cerebro-anaemic  varieties  of  headache,  in  the  table  of 
classification  at  the  head  of  this  article.     It  would  be 


4:0  HEADACHE   AND  NEURALGIA. 

an  easy  matter  to  discourse  at  length  upon  those  mod- 
ifications of  the  nervous  headache,  but  to  do  so  would 
be  somewhat  supererogatory,  since,  in  their  fundamen- 
tal characteristics,  they  are  closely  allied  to  the  latter 
affection.  The  only  point  of  difference  consists  in  the 
presence  of  certain  vaso-motor  disorders  of  the  cerebral 
blood-vessels,  which  find  their  chief  clinical  expression 
in  either  pallor  or  flushing  of  the  countenance  and  in 
diminution  or  increase  in  the  strength  of  the  carotid 
pulse.  These  circulatory  phenomena  are,  however, 
strictly  speaking,  purely  secondary  to  the  primary 
morbid  changes  in  the  cerebral  substance.  It  is 
well  to  bear  this  fact  in  mind,  since,  if  the  efforts  of 
the  physician  be  directed  solely  toward  the  modifi- 
cation of  these  vascular  changes,  he  will  inevitably 
meet  with  disappointing  results.  On  the  other  hand, 
if  appropriate  efforts  be  made  to  remove  the  primary 
condition  of  irritability,  resident  in  the  cerebral  sub- 
stance itself,  good  and  even  brilliant  results  may  often 
be  obtained  in  a  comparatively  short  period  of  time. 

Causation. — The  most  potent  predisposing  element 
is  undoubtedly  found  in  the  neurotic  and  impression- 
able constitutions  of  the  patients,  or  their  ancestry. 
Debilitating  diseases,  spermatorrhoea,  leucorrhoea, 
mental  disorders,  and  profound  digestive  disturbances 
may  also  predispose  to  the  occurrence  of  the  nervous 
or  cerebral  form  of  headache. 

Among  the  exciting  causes,  worry,  disappointment, 
pecuniary  losses,  and  in  short  the  whole  category  of 
depressing  emotions  occupy  the  most  prominent  posi- 
tion. Only  secondary  to  these  in  importance  is  ex- 
haustion of  the  nervous  centres,  particularly  those  of 
the  brain. 

Treatment. — The  point  of  paramount  importance  is 
to  calm  the  irritable  nervous  centres.     This  is  best  ac- 


NERVOUS  HEADACHE.  41 

complished  by  the  administration  of  remedies  which 
exert  a  soothing  influence  upon  the  cerebral  paren- 
chyma, and  at  the  same  time  tend  to  promote  sleep. 
To  this  end,  I  usually  administer  the  bromides  in  ten, 
twenty  or  even  thirty-grain  doses,  where  the  stomach 
is  sufficiently  tolerant,  and  follow  these  remedies  with 
a  hypodermic  injection  of  from  one-eighth  to  one-sixth 
of  a  grain  of  morphia.  At  the  same  time,  the  patient 
being  secluded  in  a  dark  room,  ice  is  applied  to  the 
head — a  procedure  often  followed  by  excellent  results, 
especially  if  there  be  some  tendency  to  cerebral  con- 
gestion. 

On  the  other  hand,  if  the  face  is  bloodless  and  the 
conjunctivae  are  pale,  the  hot- water  bag  is  indicated, 
and  should  be  resorted  to  at  once.  The  question  as 
to  whether  the  elastic  band '  should  be  applied  above 
the  superciliary  arches,  will  depend  greatly  upon 
whether  there  are  any  concomitant  neuralgic  symp- 
toms or  not.  Where  these  are  present,  the  pressure 
caused  by  the  band  is  usually  not  well  borne,  and 
consequently  this  otherwise  useful  adjunct  to  treat- 
ment is  contra -indicated. 

If  sleep  is  not  readily  produced  by  the  remedies 
above  indicated  within  a  reasonable  length  of  time, 
hyoscyamus  may  be  prescribed.  I  usually  give  it  in 
the  form  of  tincture  in  drachm  doses,  either  alone  or 
combined  with  the  bromides.  Chloral  has  been  recom- 
mended in  nervous  headache  by  some  writers,  but  is 
not  to  be  compared  with  the  hypodermic  injection  of 
morphia.        

If  the  subject,  as  not  infrequently  happens,  is  averse 

1  The  object  of  the  elastic  head-band  is  to  compress  the  vessels 
of  the  scalp,  thereby  materially  reducing  the  diffusive  influence 
of  the  extra-cranial  blood  stream,  and  rendering  the  effects  of 
cold  or  hot  applications  upon  the  brain  much  more  intense, 


42  HEADACHE  AND  NEURALGIA. 

to  its  subcutaneous  exhibition,  it  may  be  given  in  the 
form  of  suppositories,  but  the  effects  thus  obtainable 
are  not  always  as  striking  as  those  witnessed  when 
the  remedy  is  injected  beneath  the  skin. 

If  there  is  pain  over  the  temple  or  in  the  eye.  and  if 
the  subject  complain  of  "soreness  in  the  teeth  "  and 
neuralgic  pains  in  the  face,  it  is  well  to  make  the  in- 
jection in  the  neighborhood  of  the  painful  district, 
though  this  is  considered  unnecessary  by  some  authors. 

It  is  sometimes  stated  that,  while  morphia  is  very 
efficacious  at  the  beginning  of  the  attack,  it  is  of  less 
value  after  the  headache  has  continued  for  some  time. 
My  own  experience  does  not  corroborate  this  state- 
ment ;  and  I  have  not  the  slightest  hesitancy  in  stating 
that,  previous  to  the  introduction  into  practice  of 
antipyren,  this  remedy  was  the  one  upon  which  I 
based  a  goodly  portion  of  my  hopes  whether  the  pa- 
tient was  seen  after  the  pains  have  become  estab- 
lished, or  at  their  very  inception. 

The  aim  of  the  physician,  when  brought  face  to  face 
with  a  severe  case  of  uervous  headache,  should  be  to 
afford  relief,  and  that  as  speedily  as  possible  :  indeed 
it  is  almost  impossible  to  overestimate  the  suffering 
incident  to  one  of  these  attacks  ;  and  the  confidence 
and  gratitude  inspired  by  prompt  and  succesful  treat- 
ment are  a  source  of  lasting  satisfaction  to  physician 
and  patient  alike .  On  the  other  hand,  want  of  success 
brings  mortification,  if  not  permanent  loss  of  profes- 
sional prestige.  If  possible,  it  is  well  to  see  the  patient 
towards  evening,  when  the  soporific  tendency  conse- 
quent upon  habit  is  greatest . 

As  soon  as  a  diagnosis  has  been  made,  antipyren 
may  be  exhibited  in  doses  of  fifteen  grains  every 
twenty  minutes  during  the  first  two  hours.  The 
bromides  may  then  be  given  —  preferably  in  a  dose 


NERVOUS  HEADACHE.  43 

of  from  twenty  to  thirty  grains  in  conjunction 
with  one  drachm  of  the  tincture  of  hyoscyamus. 
Should  there  still  be  persistent  pain  the  eighth  of 
a  grain  of  morphia  may  be  injected  beneath  the 
skin.  Sympathizing  friends  should  then  be  sent 
away,  and  the  patient  allowed  to  remain  quiet  in 
a  perfectly  dark  room,  while  the  medical  attendant 
occupies  a  neighboring  apartment,  leaving  the  door 
ajar.  If  in  due  course  of  time  the  patient  fall  asleep, 
the  attendant  may  depart,  resting  assured  that  on 
the  following  morning  there  will  be  improvement,  if 
not  absolute  cure.  Should  sleep,  however,  remain 
absent  after  these  first  endeavors,  there  should  be  no 
hesitancy  on  the  part  of  the  physician  in  resorting  to 
a  further  hypodermic  injection  of  morphia,  even  though 
there  be  nausea  and  a  tendency  to  vomit.  Usually, 
though  not  always,  the  nausea  may  be  controlled  by 
giving  half  a  grain  of  cocaine  in  a  teaspoonful  of  water 
just  previous  t:>  making  the  injection.  I  make  it  an 
invariable  rule  never  to  leave  the  patient  until  sleep 
has  been  produced,  as  the  therapeutic  effects  of  eight 
or  nine  hours  of  unconsciousness  are  simply  marvellous 
in  these  cases.  Sleep,  indeed,  is  the  grand  objective 
point  of  all  treatment,  in  so  far  as  the  realization  of 
permanent  cure  is  concerned.  Its  skillful  induction  in 
the  cases  which  we  are  considering  will  often  procure 
the  physician  lasting  gratitude,  with  the  advantages 
which  naturally  follow. 


CHAPTER   V. 

TOXIC   HEADACHE. 

This  form  of  headache  is  caused  by  some  chemical 
change  in  the  constitution  of  the  blood,  due  either  to 
poisonous  substances  introduced  into  the  system  from 
without,  or  evolved  in  the  economy  itself  through  the 
agency  of  some  organic  or  functional  derangement. 

The  best  instance  of  the  first  named  condition  is  the 
headache  due  to  alcoholic  poisoning  ;  while  the  head- 
pains  of  Bright's  Disease  and  of  fevers,  are  examples 
of  the  effects  produced  by  septic  influences  arising 
from  morbid  processes  within  the  organism  itself. 

Symptoms.  —The  nature  of  the  pains  arising  from 
toxsemic  causes  is  variable  in  character.  Sometimes 
the  subject  complains  of  a  heavy,  dull  sensation  in  the 
head,  which  may  or  may  not  be  accompanied  by  ver- 
tigo. Again,  the  pain  is  sharp,  and  is  described  as 
splitting  or  boring.  This  is  the  form  of  headache 
described  by  Fournier; 1  it  is  frequently  met  with 
among  other  phenomena  of  secondary  syphilis. 

According  to  the  extent  of  the  intoxication,  the  fac- 
ulties of  the  mind  are  more  or  less  affected.  There 
may  be  delirium  as  in  violent  febrile  disturbances,  or 
the  only  symptoms  noticed  are  heaviness  and  slight 
mental  confusion,  as  in  the  heada.che  resulting  from 
inhalation  of  carbonic  acid  gas. 

The  latter  form  of  headache  is  frequently  met  with 
among  the  school  children  of  Germany,  who,  owing  to 

1  Fournier,  "  Lecons  sur  la  Syphilis,'"  Paris,  1873. 


TOXIC  HEADACHE.  45 

the  defective  ventilation  of  educational  institutions, 
are  conmelled  to  breathe  the  same  air  over  and  over 
again.  The  prejudicial  effects  of  such  bad  hygienic 
arrangements  are  not  alone  confined  to  the  central 
nervous  system,  but  are  visible  in  other  departments 
of  the  economy  as  well.  Facial  pallor,  baggy  muscles 
and  permanent  interference  with  the  processes  of 
growth  and  physical  evolution  are  some  of  the  penal- 
ties which  are  the  inevitable  result  of  flagrant  dis- 
regard of  the  most  ordinary  sanitary  laws. 

Among  workers  in  brass  and  chemical  manufac- 
tories a  dull,  heavy,  persistent  form  of  headache  is  fre- 
quently encountered,  which  is  evidently  the  result  of 
the  noxious  fumes  such  persons  are  compelled  to  inhale 
during  a  considerable  portion  of  each  day. 

Chronic  lead  poisoning  frequently  gives  rise  to  head- 
ache of  an  aggravated  and  persistent  type,  and  the 
same  may  be  said  of  the  toxic  effects  of  a  large  num- 
ber of  other  substances,  such  as  the  noxious  gases 
already  alluded  to,  narcotics,  and  alcoholic  stimulants. 

Uramiic  intoxication  is  another  and  common  source 
of  headache.  The  secretory  power  of  the  kidneys  be- 
comes impaired  by  reason  of  the  destructive  inflamma- 
tory changes  incident  to  chronic  diseases ;  the  excre- 
mentitious  matters  of  the  blood  accumulate,  and  their 
presence  is  manifested  by  disturbances  of  the  central 
nervous  system — headache,  drowsiness  and  coma. 
Every  physician  is  acquainted  with  cases  of  this  kind, 
and  nothing  more  need  be  said  regarding  them,  except 
that  the  headache  in  question  is  often  an  early  warn- 
ing of  renal  trouble. 

Treatment. — When  the  headache  is  the  result  of  the 
introduction  of  some  noxious  substance  into  the  sys- 
tem, every  effort  should  be  made  to  eliminate  it  from 
the  economy.     The  bowels  should  be  opened  ;  diuretics 


46  HEADACHE  AND  NEURALGIA. 

should  be  given,  and  the  secretions  of  the  skin  stimu- 
lated by  appropriate  diaphoretics. 

Buckthorn  (rhamnus),  a  purgative  which  I  have 
found  most  useful  in  asylum  practice,  is  particularly 
applicable  in  this  variety  of  headache  ;  it  may  be  given 
in  the  form  of  the  fluid  extract,  in  doses  of  from  one 
to  two  drachms.  The  fluid  extract  of  aloes  may  also 
be  given,  but  I  prefer  the  buckthorn.  Whatever  the 
purgative  employed  it  should  be  fluid  in  form,  in  order 
to  obtain  as  speedy  action  as  possible. 

Pilocarpin  is  useful,  but  I  prefer  the  Turkish  or 
Kussian  bath. 

If  the  headache  be  the  result  of  some  form  of  con- 
stitutional disease,  such  as  syphilis,  it  is  evident  that 
the  efforts  of  the  physician  should  be  directed  to  the 
primary  affection.  The  same  may  be  said  of  the  head- 
aches of  fevers  and  kidney  affections.  It  is  clear, 
from  these  cursory  remarks,  that  the  proper  treatment 
of  this  form  of  headache  requires  no  little  insight  and 
tact  on  the  part  of  the  medical  attendant.  To  attempt 
to  deal  with  such  cases  by  the  aid  of  any  stereotyped 
procedure  would  avail  little;  and  to  lay  down  any  such 
arbitrary  laws  on  the  subject,  would  be  but  a  lament- 
able confession  of  pedantry. 


CHAPTER  VI. 

SYMPATHETIC  HEADACHE,  BILIOUS  HEADACHE. 

This  is  a  very  common  though  obscure  form  of  head- 
ache, being  dependent  upon  eccentric  sources  of  irrita- 
tion. Any  disease  of  the  peripheral  organs  may  cause 
it.  Ovarian  or  uterine  affections,  hemorrhoids  or 
decayed  teeth  may  give  rise  to  it ;  but  its  most  prolific 
cause  is  undoubtedly  found  in  the  manifold  digestive 
disturbances,  to  which  those  of  feeble  constitution  are 
liable.  It  would  be  a  mistake,  however,  to  imagine 
that  the  sole  explanation  of  its  origin  is  to  be  sought 
in  peripheral  disturbances  alone,  though  these  un- 
doubtedly constitute  the  exciting  factor.  A  certain 
impressionability  of  the  sensorium,  such,  for  example, 
as  that  exhibited  by  neurotic  young  women,  is  essen- 
tial, in  order  that  the  irritation  proceeding  from  a  dis- 
tance shall  culminate  in  the  production  of  the  painful 
sensations. 

All  kinds  of  hypotheses  have  been  advanced  in  ex- 
planation of  these  curious  head -pains  ;  the  most  uni- 
versally accepted  is  that  which  assumes  that  the  peri- 
pheral irritation  becomes  manifest  in  the  brain  through 
the  agency  of  the  pneumogastrics  and  sympathetic 
system  of  nerves.  Quite  an  array  of  clinical  facts 
might  be  advanced  in  support  of  this  theory  ;  but  to 
maintain  its  integrity  by  the  aid  of  experimental  physi- 
ology is,  in  the  present  state  of  knowledge,  not  so  easy 
a  matter.  Still,  some  theory  is  better  than  none  at 
all,  and  pending  further  researches,  the  opinions  cur- 


4§  Headache  and  neuralgia. 

rently  advocated  may  be  accepted.  Nor  need  this 
course  cause  apprehension,  since  the  theory  itself  is  a 
good  guide,  as  far  as  actual  practice  is  concerned;  and 
can  only  lead  to  enlightened  treatment.  Of  the  latter 
point  I  shall  take  occasion  to  speak  presently. 

As  to  the  Symptoms  themselves,  very  little  particu- 
larization  is  necessary.  Sometimes  the  pain  is  local 
in  character  and  may  manifest  itself  in  a  sensation  of 
fullness  or  constriction  about  the  forehead,  or  it  may 
oe  of  a  rasping,  clawing  nature,  confining  itself  to  one 
lateral  half  of  the  head  or  to  the  region  of  the  vertex. 

As  a  rule,  the  painful  sensations  are  aggravated  by 
stimulants  ;  but  this  is  owing,  in  part  at  least,  to  the 
digestive  disturbances  which  so  frequently  constitute 
the  exciting  cause  of  the  affection.  That  form  of 
headache  characterized  by  the  presence  of  a  yellow 
skin,  by  the  accumulation  of  bile  in  the  duodenum, 
and  by  more  or  less  imperfect  digestion,  has  received 
the  designation  of  "  bilious  headache."  There  is 
every  reason,  however,  to  regard  this  variety  of  head- 
pain  as  of  purely  sympathetic  origin,  since  the  head- 
ache comes  on  after  the  digestive  disturbances  have 
become  established,  and  disappears  as  soon  as  they 
have  been  removed.  It  is  a  matter  of  common  ex- 
perience, moreover,  that  the  "sick"  headache  which 
supervenes  upon  minor  gastric  disorders  is  frequently 
relieved  immediately  by  vomiting. 

True  bilious  headache  is  more  common  among  men 
than  among  women,  on  account  of  the  excesses  of  the 
table  committed  by  the  former. 

The  pain  may  begin  after  any  meal,  but  is  more 
common  after  a  hearty  evening  dinner  than  after  lunch 
or  breakfast.  Sometimes,  however,  the  headache  be- 
gins in  the  morning  as  the  result  of  a  previous  noctur- 
nal debauch,  and  renders  the  subject  entirely  unfit  for 


SYMPATHETIC  AM)  BILIOUS   HEADACHE.  49 

the  duties  of  the  day.  The  head  may  be  hot  or  cold, 
but  whatever  the  vascular  conditions  they  are  sec- 
ondary to  the  cerebral  irritability  which  is  the  factor 
of  prime  importance.  If  vomiting  takes  place  spon- 
taneously or  by  the  aid  of  emetics,  the  relief  experi- 
enced is  often  magical.  When,  however,  the  gastric 
and  cerebral  disturbances  have  persisted  for  a  con- 
siderable length  of  time,  the  consequent  irritability  and 
exhaustion  of  the  nervous  centres  is  so  great  that  the 
only  chance  of  relief  is  more  or  less  prolonged  un- 
consciousness. Under  these  circumstances,  sleep  is 
certainly  the  remedy  par  excellence;  and  to  procure 
it,  resort  should  be  had  to  hypodermic  medication 
alone,  as  the  introduction  of  remedies  into  the  in. 
flamed  stomach  is  usually  followed  by  vomiting,  or  at 
least  great  discomfort. 

Treatment. — The  control  of  a  single  attack  is,  as  we 
have  seen,  a  matter  of  no  great  difficulty.  To  finally 
vanquish  and  definitely  suppress  the  exciting  cause 
of  these  paroxysms  is,  however,  a  task  of  greater 
magnitude.  It  involves  in  many  cases  nothing  less 
than  the  removal  of  dyspeptic  and  other  gastric  diffi- 
culties of  long  standing,  and  the  tranquilization  of  a 
morbidly  irritable  nervous  system.  The  first  portion 
of  the  problem  requires  for  its  solution  the  manifold 
resources  of  general  medicine.  As  to  the  suppression  of 
morbid  irritability  of  the  nervous  centres,  all  that  has 
been  said  on  the  subject  in  the  paragraph  on  cerebral 
or  ''nervous  "  headache  applies  here  with  equal  force. 
I  will  only  add  that  the  preparations  of  coca  often 
prove  exceedingly  useful  in  treating  this  form  of  head- 
ache. This  is  partly  due  to  the  anaesthetic  effect  of 
the  drug  upon  the  irritable  gastric  mucous  membrane  ; 
and  in  part  to  the  tranquillizing  influence  exercised  by  • 
the  coca  upon  the  higher  cerebral  centres, 
4 


50  HEADACHE  AND  NEURALGIA. 

As  all  practitioners  are  aware,  one  of  the  most  disa- 
greeable features  connected  with  the  treatment  of  this 
form  of  headache  consists  in  the  intolerance  of  the 
stomach  to  remedies.  Until  the  introduction  of  the 
coca  preparations  into  practice,  I  was  frequently  at  no 
little  loss  as  to  the  pursuit  of  a  consistent  plan  of  med- 
ication in  such  cases,  owing  to  this  same  intolerant 
condition  of  the  stomach.  I  soon  ascertained,  however, 
that  by  adding  a  certain  quantity  of  the  fluid  extract 
of  coca  to  the  remedy  that  I  was  anxious  to  prescribe, 
the  latter  was  borne  with  much  less  inconvenience. 
The  good  effects  thus  attained  were  greatly  enhanced 
by  the  addition  of  half  a  grain  of  cocaine  or  more. 
This  was  particularly  exemplified  in  those  cases  where 
I  had  occasion  to  prescribe  considerable  quantities  of 
the  bromides  A  pill  compound  of  :  Res.  Podophylli 
gr.  -§,  Extr.  Col.  comp.  pulv.  gr.  1,  Extr.  Hyoscyami 
gr.  ;j,  Hydrarg.  Chlor.  mit.  gr.  1,  is  an  excellent  cath- 
artic where  brisk  action  on  the  liver  is  desired.  The 
addition  of  a  small  quantity  of  the  extr.  of  belladonna 
is  advisable  where  the  tendency  to  griping  is  pro- 
nounced. 

The  following  formula,  recommended  by  Day,  some- 
times renders  good  service  where  there  is  a  tendency 
to  flatulence  and  acidity  : 

5 


Sodse  Bicarb. 

Bismuth  Subcarb. 

Pulv.  Acaciae,  aa. 

3]\ 

Spt.  Amm.  Arom., 

3ij. 

Sqr.  Zingib., 

3  iij. 

Aquas  purae,  ad. 

!  viii, 

Two  tablespoonfuls  three  times  a  day  half  an  hour 
before  eating.  Here  also  the  efficacy  of  the  prescrip- 
tion is  greatly  enhanced  when  its  administration  is 


SYMPATHETIC  AND  BILIOUS  HEADACHE.  51 

preceded  by  giving  cocaine  hydro-chlorate,  half  a  grain 
in  a  teaspoonful  of  water.  I  have  tested  this  point 
many  times,  often  in  exceedingly  intractable  cases. 

Bismuth  in  doses  of  from  fifteen  to  twenty  grains 
before  meals  may  be  given  where  there  is  evidence  of 
intestinal  irritability. 

Sometimes  two  or  three  drops  of  the  tincture  of  nux 
vomica  given  every  half  hour  for  three  or  four  hours 
renders  good  service. 

An  excellent  expedient  is  that  of  Dr.  A.  A.  Smith,1 
who  gives  half  a  drachm  of  saccharated  pepsin  in  a 
wineglassful  of  sherry  three  times  a  day  at  meal  times. 
A  drop  or  two  of  the  tincture  of  acouite,  given  in  a 
small  quantity  of  water  and  repeated  at  intervals,  some- 
times proves  efficacious  where  the  pulse  is  small  and 
rapid. 

Where  the  extremities  are  cold  the  application  of 
hot-sand  bags,  which  have  previously  been  covered 
with  flannel,  proves  beneficial  by  equalizing  the  cir- 
culation and  promoting  the  general  comfort  of  the  pa- 
tient. Quinine  may  also  be  given  when  there  is  a 
suspicion  of  malaria,  or  when  there  is  pronounced 
facial  pallor  and  weak  carotid  pulse;  but  should  there 
be  the  slightest  suspicion  of  cerebral  congestion  it 
should  be  withheld. 

1  A  lecture  delivered  at  the  Bellevue  Hospital  Medical  College. 
"The  Medical  Record,"  September  15th,  1876. 


y 


CHAPTER  VII. 

ORGANIC  HEADACHE,  OR  THAT  WHICH  IS  DEPENDENT 
UPON  PROFOUND  CHANGES  IN  THE  CONSTITUTION  OF 
THE  BRAIN   OR  ITS   MEMBRANES. 

The  consideration  of  this  variety  of  head-pain  does 
not  strictly  speaking  belong  in  a  work  of  this  charac- 
ter. For  the  sake  of  differential  diagnosis,  however, 
a  word  or  two  respecting  its  more  important  charac- 
teristics will  be  found  of  service. 

Headaches  due  to  organic  disease  of  the  brain  are 
usually  more  or  less  continuous  in  character  and  are 
(referred  to  a  circumscribed  portion  of  the  cranium.) 
There  may  or  may  not  be  accompanying  disturbances 
of  sensation  and  motion  assuming  the  form  of  local 
spasms,  paresis  or  impairment  of  vision.  J 

Sometimes  cases  are  encountered  in  which  progres- 
sive loss  of  muscular  power,  vertigo,  visual  impair- 
ment and  derangement  of  the  faculty  of  recollection 
are  the  prominent  symptoms.  If  headache,  accom 
panied  by  epileptic  phenomena,  disturbances  of  speech 
and  facial  paralysis,  takes  place  a/t  the  period  of  ado- 
lesence,  there  is  strong  presumptive  evidence  that  we 
have  to  do  with  organic  disease,  more  especially  if  a 
history  of  previous  syphilis  is  forthcoming. 

The  probability  that  a  correct  diagnosis  has  been 
made  is  considerably  enhanced  if  there  is  vomiting 
and  inability  to  retain  food  on  the  stomach,  in  the 
absence  of  obvious  gastric  disturbance. 


ORGANIC    HEADACHE.  53 

Organic  disease  is  by  no  means  as  frequent  a  cause 
of  headache  as  might  be  imagined  from  the  percent- 
age of  gross  cerebral  lesions. )  Nor  is  the  diagnosis  of 
this  form  of  headache  always  an  easy  matter  J  Some- 
times the  headache  resulting  from  organic  changes 
may  be  circumscribed  in  character  and  located  by  the 
patient  with  great  precision ;  whereas  a  subsequent 
post-mortem  examination  may  prove  such  localization 
to  be  entirely  subjective,  the  lesion  being  found  in  an 
entirely  different  portion  of  the  brain.  Again,  there 
may  be  more  or  less  profound  organic  changes  without 
headache ;  or  there  may  be  intense  local  pains,  more 
or  less  persistent  in  character,  and  which  are  wholly 
due  to  some  circulatory  instability. 

In  the  face  of  such  facts,  it  is  evident,  that  only 
by  the  exercise  of  the  utmost  caution  is  the  liability 
of  error  to  be  reduced  to  a  mininum. 

Causes. — The  lesions  which  are  most  liable  to  give 
rise  to  this  form  of  headache  are  :  arterial  disease,  sy- 
philitic and  other  varieties  of  tumor,  tuberculosis, 
cerebral  softening,  hydatids  and  ossified  formations 
within  the  cranial  vault  and  meningitis. 

Treatment.  —The  treatment  of  headache  due  to  or- 
ganic lesions  of  the  intra-cranial  structures  is  in  the 
highest  degree  unsatisfactory,  as  far  as  the  prospect 
of  ultimate  recovery  is  concerned.  This  at  least  is 
true  as  regards  non-syphilitic  lesions.  Where  there 
is  reason  to  believe  that  the  disturbances  are  due  to 
the  presence  of  syphilis,  the  iodide  of  potassium  should 
be  given  in  large  doses  two  or  three  times  a  day,  and 
the  treatment  persisted  in  until  improvement  becomes 
evident.  Sometimes  there  is  no  apparent  benefit  in 
the  beginning ;  but  this  should  not  deter  the  practi- 
tioner from  persevering  in  the  only  course  which  offers 
the  slightest  hope  of  ultimate  amelioration. 


54  HEADACHE  AND  NEURALGIA. 

And  it  must  be  confessed  that  great  patience  will  be 
required,  both  on  the  part  of  the  patient  and  physician, 
in  order  to  withstand  the  lack  of  success  which  fre- 
quently attends  the  beginning  of  this  heroic  medica- 
tion. Sooner  or  later,  however,  if  the  lesion  be  really 
due  to  syphilis,  improvement  may  occur,  and  the 
spectacle  of  the  patient's  improvement  under  such 
unpromising  circumstances  is  an  ample  reward  for  all 
previous  anxiety. 

The  iodide  of  potassium  has  been  recommended  as 
efficacious  in  the  treatment  of  non-syphilitic  tumors, 
as  well  as  in  those  traceable  to  specific  influences.  I 
cannot  say  that  the  bulk  of  clinical  evidence  accessible 
up  to  date  goes  far  to  confirm  this  opinion ;  but  in 
spite  of  this  fact,  it  is  evident  that  the  iodide  should 
always  be  given  a  fair  trial  in  all  doubtful  cases. 

As  to  the  treatment  of  the  pains  themselves,  mor- 
phine is  unquestionably  the  remedy  upon  which  the 
greatest  reliance  is  to  be  placed.  There  is  one  draw- 
back to  its  administration,  however,  the  serious  de- 
pression which  it  sometimes  produces  in  neurotic, 
irritable  subjects.  This  collateral  disadvantage  is 
best  overcome  by  the  administration  of  one  of  the  coca 
preparations, —either  the  extract  or  Mariani's  coca 
wine.  I  usually  give  the  latter  in  wineglass  doses 
as  soon  as  there  is  the  slightest  tendency  to  depression. 
The  amount  of  morphine  required  is  of  course  exceed- 
ingly variable  ;  usually,  however,  one-sixth  of  a  grain 
will  be  found  to  render  good  service,  especially  if  fol- 
lowed by  a  drachm  of  the  tincture  of  hyoscyamus,  or 
ten  grains  of  chloral.  The  latter  remedy  when  given 
alone  or  in  conjunction  with  the  bromides  usually  fails 
to  render  substantial  aid  ;  and  I  would  therefore  insist 
that  opium  in  some  form  be  invariably  given  previous 
to  the  exhibition  of  the  chloral  preparations.     Anti- 


ORGANIC    HEADACHE.  55 

pyren  has  not  helped  me  much  in  this  class  of  cases, 
when  given  alone.  In  conjunction  with  small  doses 
of  morphine,  however,  I  have  seen  good  results  follow 
its  exhibition. 


CHAPTER  VIII. 

CASES. 

Having  in  the  preceding  chapters  discussed  the  prin- 
cipal phases  of  headache,  it  may  perhaps  prove  of 
benefit  to  cite  a  few  illustrative  cases: — 

T.  B.,  a  merchant,  native  of  St.  Kitts,  West  Indies, 
was  referred  to  me  by  the  late  Dr.  Cornelius  R.  Ag- 
new,  on  account  of  severe  headaches,  accompanied  by 
certain  mental  disturbances,  such  as  temporary  loss  of 
memory  and  lassitude. 

♦  Patient  had  already  consulted  several  eminent  Eng- 
lish authorities,  among  whom  I  believe  was  Sir  Andrew 
Clarke.  When  I  first  saw  this  gentleman  in  November, 
1886,  he  exhibited  the  following  symptoms  : 

Periodic  exacerbations  of  cerebral  hyperaemia,  ac- 
companied by  tensive  pains  and  sensations  of  fullness 
in  the  head.  Sometimes  there  is  vertigo;  at  others 
the  patient,  though  ordinarily  of  an  even  disposition, 
is  irritable  and  aroused  to  worry  and  fretfulness  by 
trivial  or  imaginary  causes. 

The  heart's  action  is  also  more  or  less  increased  dur- 
ing the  attack.  During  the  head-pains  the  face  is  suf- 
fused, whereas  at  other  times  his  complexion  is  of  a 
yellowish  grey  appearance. 

Patient  has  suffered  from  constipation  for  many 
years,  and  of  late  his  venereal  functions  have  exhibited 
a  well-marked  decline. 

I  prescribed    purgatives  and  the    bromides,   with 


CASES.  57 

directions  10  take  a  hot  bath  as  soon  as  the  first 
symptoms  of  an  impending  attack  should  make  their 
appearance.  While  sitting  in  the  bath,  the  warm 
water  extending  up  to  his  arm- pits,  I  instructed  him  to 
press  upon  his  carotid  arteries  with  an  implement  which 
I  loaned  him  for  the  purpose.  These  simple  meas- 
ures never  failed  to  give  him  instant  relief.  On  one 
occasion  he  had  a  slight  attack  of  syncope  while  in 
the  bath,  and  the  attendant,  who  was  always  present, 
removed  him  at  once.  There  were  no  further  evil 
effects  from  the  treatment  that  I  ever  heard  of  ,  nor 
do  I  believe  that  this  slight  syncope  need  have  oc- 
curred had  the  patient  obeyed  my  injunction  not  to 
remain  in  the  bath  more  than  ten  minutes,  which  for 
a  man  of  his  age  was  quite  enough. 

By  prohibiting  alcohol  and  cutting  down  the  patients' 
diet  somewhat,  the  headaches  were  eventually  entirely 
cured  ;  but  I  never  succeeded  in  entirely  abolishing  a 
peculiar  "buzzing  sensation  in  the  head"  (tinnitus?), 
of  which  the  patient  complained  more  or  less  while 
under  my  care. 

A.  N.  D.,  a  young  woman  of  twenty,  consulted  me 
on  account  of  severe  headaches,  from  which  she  suffers 
more  or  less  constantly,  and  more  especially  during 
the  menstrual  period.  She  is  an  excellent  illustration 
of  that  common  class  of  head- pains  which  is  the  direct 
result  of  the  devitalized  and  anaemic  condition  of  the 
patient.  For  the  last  four  years  she  has  suffered 
from  dysmenorrhcea  ;  her  appetite  is  poor,  and  she  has 
been  a  victim  of  constipation  more  or  less  during  her 
whole  life.  Her  heart's  action  is  weak,  as  reflected  in 
a  feeble  pulse,  which  at  times  is  irregular.  Her  com- 
plexion has  a  tawney,  sallow  appearance,  the  conjunc- 
tiva is  pale  and  the  pupils  somewhat  dilated. 

The  indications  afforded  by  the  carotids  were  also 


5S  HEADACHE  AND  NEURALGIA. 

characteristic.  When  the  head  was  thrown  slightly 
backwards  so  as  to  protrude  the  cervical  vertebrae  in 
an  anterior  direction,  these  arteries  are  seen  to  pulsate 
slightly  ;  but  on  applying  the  finger  they  are  found  to 
be  decidedly  more  compressible  than  in  healthy  or 
hyperaemic  individuals.  When  both  arteries  are  com- 
pressed by  the  aid  of  an  appropriate  instrument,  sen  • 
sations  of  faintness  are  at  once  induced.  On  suddenly 
rising  from  the  recumbent  posture  this  feeling  of 
faintness  may  also  be  induced,  and  at  the  same  time 
the  characteristic  "clawing"  pains  of  anaemia  are  at 
once  evoked.  There  is  some  sensitiveness  to  light, 
but  no  special  hyperesthesia  of  the  sense  of  hearing. 

The  diagnosis  in  such  a  case  as  this  is  at  once  appar- 
ent :  in  a  word,  we  have  to  do  with  a  typical  case  of 
anaemic  headache  ;  and  the  indications  for  treatment 
are  the  counteracting  of  all  those  features  implied  by 
the  word  anaemia. 

In  the  first  place  relief  of  the  cerebral  anaemia  by 
alcohol,  with  consequent  immediate  stoppage  of  the 
headache. 

For  the  purpose  of  further  facilitating  the  blood- 
flow  to  the  cerebrum,  the  patient  is  to  be  kept  upon 
her  back. 

Finally,  in  order  to  secure  permanent  results,  the 
patient's  appetite  is  to  be  stimulated  by  bitters,  and  she 
is  to  be  put  upon  a  course  of  systematic  over-feeding. 
Exercise  is  to  be  studiously  avoided  in  a  case  of  this 
kind,  at  least  until  there  is  total  disappearance  of  the 
head-pains.  Towards  the  end  of  treatment,  massage 
and  general  faradization  may  be  resorted  to,  usually 
with  great  benefit. 

Nothing  of  the  kind  should,  however,  be  attempted 
at  first  on  account  of  the  danger  of  diverting  the  blood- 
stream from  the  already  impoverished  nerve  centres. 


CASES.  59 

Under  the  treatment  indicated,  the  improvement 
in  this  case  took  place  with  reasonable  promptness. 
At  the  end  of  a  month  there  were  no  pains  of  conse- 
quence ;  the  patient  had  already  gained  several  pounds, 
and  I  was  able  to  allow  her  to  go  about  a  little.  From 
this  time  forwards,  her  improvement  was  a  rapid  one, 
so  that  at  the  end  of  three  months,  with  the  exception 
of  the  dysmenorrhcea,  she  was  entirely  cured  and  she 
could  take  her  place  in  society  without  discomfort. 

C.  E.  T.,  middle-aged  married  lady,  has  suffered  ever 
since  girlhood  from  "  sick-headache." 

The  pain  is  exceedingly  intense,  and  is  generally  lo- 
cated in  the  forehead.  The  attacks  usually  begin  in 
the  afternoon,  but  this  is  not  always  the  case.  Soon 
after  she  feels  the  premonitory  symptom  of  the  attack 
— a  "  dull  feeling  in  the  head  " — she  is  afflicted  by  in- 
tense nausea,  which  is  speedily  followed  by  vomiting. 

These  symptoms  are  invariably  followed  by  vertigo, 
great  mental  depression  and  prostration,  so  that  she 
is  obliged  to  take  to  her  bed,  where  she  remains  till 
the  middle  of  the  following  day.  When  she  is  able 
to  obtain  relief,  there  is  practically  an  end  of  the  mat- 
ter on  the  following  day  ;  but  where  unconsciousness 
fails  to  come  to  the  rescue,  there  is  much  pain  on  the 
following  day,  and  the  headache  may  even  persist  for 
three  days  or  more. 

Her  complexion  is  sallow,  her  appetite  fair  ;  but 
her  digestion  is  habitually  impaired,  and  she  has  always 
suffered  from  constipation. 

In  her  case  a  pill  of  podophylline  and  extr.  col. 
comp.  with  i  gr.  of  hyoscyamus  and  1  gr.  hydrarg. 
chlor.  mit.  never  failed  to  give  relief .  In  addition  to 
this  I  am  in  the  habit  of  giving  her  large  doses  of  bro- 
mo-caffein  combined  with  grain  doses  of  the  hydro- 
chlorate  of  cocaine,  the  latter  being  administered  in 


60  HEADACHE  AND  NEURALGIA. 

half  a  tablespoonful  of  water,  ten  minutes  before  giv- 
ing the  bromo-caffein.  She  declared  that  she  obtained 
more  prompt  relief  from  these  measures  than  from 
anything  she  had  ever  tried.  Her  tendency  to  diges- 
tive trouble,  however,  still  remained  a  factor  of  such 
obstinacy  that,  with  all  I  could  do  for  her,  I  was  never 
able  to  effect  a  final  abolition  of  the  attacks,  which 
occurred  upon  the  slightest  indiscretion  of  the  table, 
and  even  as  the  result  of  comparatively  slight  worry, 
where  there  was  no  history  of  any  indiscretion  what- 
ever. This  is  a  typical  case  of  that  form  of  megrim 
of  which  every  practitioner  of  large  experience  en- 
counters many  cases  every  year. 

In  giving  these  brief  histories  of  the  more  common 
forms  of  intra  cranial  pain,  I  trust  that  I  have  not 
trespassed  too  much  upon  the  patience  of  the  reader. 

It  is  now  in  order  to  consider  the  second  and  larger 
field  of  our  subject,  the  extra-cranial  pains  and  those 
co- related  phases  of  neuralgia  involving  the  peripheral 
nerves  at  large.  It  has  also  seemed  appropriate  to 
supplement  the  discussion  by  a  chapter  on  that  inter- 
esting and  important  affection  known  as  spinal  irrita- 
tion. 


PART  II. 


NEURALGIA. 


PAINS  WHICH   OWE  THEIR  ORIGIN  TO 
EXTRA-CRANIAL  CAUSES. 


CHAPTER   IX. 

GENERAL   CONSIDERATIONS. 

Under  the  designation  of  neuralgia,  I  propose  to 
consider  an  affection  of  the  nerves,  the  chief  charac- 
teristic of  which  is  severe  and  sudden  pain  occurring 
in  one  or  more  nerve  trunks  and  radiating  towards 
the  periphery. 

Characteristics. — As  Dr.  Anstie1  has  rightly  ob- 
served, the  first  attack  is  always  preceded  by  a  condi- 
tion of  debility  resulting  from  general  or  special  causes. 
The  disease  is  especially  liable  to  occur  in  those  whose 
delicate  constitutions  render  them  susceptible  to  sud- 
den changes  in  the  weather  or  cold  draughts  of 
air.  This  applies  with  particular  force  to  persons 
of  neurotic  temperament,  in  whom  the  power  of  ac- 
commodation to  violent  and  rapid  changes  of  tempera- 
ture is  but  imperfectly  developed. 

The  onset  of  the  disease  is  usually  heralded  by  vague 
muscular  twitch  ings  or  sensations  of  pricking,  quickly 
succeeded  by  evanescent  darting  pains.  The  pains 
are  recurrent  in  character,  and  succeed  each  other 
with  ever-increasing  frequency  and  intensity,  until, 
in  the  more  severe  attacks,  the  patient  suffers  the 
most  excruciating  agony. 

Sometimes  the  pains  are  described  as  resembling 
the  sensations  produced  by  the  prick  of  red-hot 
needles  ;  at  others  the  subject  complains  that  he  feels 
as  though  he  were  being  lacerated  with  a  saw,  or  as 

1  "  Neuralgia  and  the  Diseases  that  resemble  it."    London,  1871. 


64  HEADACHE  AND  NEURALGIA. 

if  electric  sparks  were  projected  along  the  course  of 
his  nerves.  These  pains  are  sometimes  stationary 
and  are  ascribed  by  the  subject  to  particular  districts, 
which  are  found  to  correspond  to  the  course  of  a  nerve 
trunk.  At  other  times  they  are  ambulatory  and  dart 
from  place  to  place — usually  from  the  centre  towards 
the  periphery,  but  sometimes  in  an  opposite  direction. 
On  the  application  of  pressure  above  the  affected  nerve, 
the  la.tter  is  often  found  to  be  extremely  hypersesthetic 
throughout  its  entire  course,  whereas,  on  the  other 
hand,  in  a  considerable  number  of  cases  exploration 
with  the  point  of  the  finger  reveals  the  existence  of 
isolated  painful  spots — "  the  painful  points  "  of  Vallei. 
These  painful  spots  are  usually  located  at  the  points 
where  the  nerve -stems  emerge  from  bony  canals,  or 
transfix  fibrous  tissue.  They  are  present  in  the  major- 
ity of  cases  of  neuralgia,  and  careful  digital  explora- 
tion will  rarely  fail  to  result  in  their  accurate  localiza- 
tion. When  exploration  with  the  finger  fails  to  reveal 
the  presence  of  these  puncta  dolorosa,  they  may  fre- 
quently be  discovered  by  resort  to  the  induced  current, 
applied  by  means  of  the  wire  brush.  The  latter  should 
be  gently  applied  along  the  course  of  the  suspected 
nerve,  the  strength  of  the  current  being  gradually  in- 
creased or  decreased,  to  suit  the  susceptibility  of  the 
individual.  A  small  sponge  electrode  may  be  substi- 
tuted for  the  wire  brush  ;  but  I  prefer  the  latter,  pro- 
vided that  the  current  can  be  acccurately  regulated. 
Where  the  state  of  the  nervous  system  is  one  of  ex- 
treme irritability,  the  pains  are  sometimes  distributed 
by  irradiation  to  districts  remote  from  the  seat  of  the 
primary  lesion.  It  has  been  asserted  by  Trousseau 
that  pressure  applied  to  the  vertebrae  situated  at  the 
origin  of  the  painful  nerves,  causes  pain  in  all  neural- 
gic affections.     These  sensitive  areas  along  the  course 


GENERAL    CONSIDERATIONS.  65 

of  the  cord  have  been  designated  by  this  author  as 
"points  apophysaire,  or  spinous  points."  l 

It  is  evident,  however,  that  there  is  nothing  pathog- 
nomic in  the  phenomena,  since  they  may  be  present 
in  several  affections  of  the  spinal  cord;  but,  neverthe- 
less, they  call  for  special  local  treatment,  of  which 
more  will  be  said  in  the  Appendix  on  spinal  irritation. 

Disturbances  of  sensation  are  frequently  encoun- 
tered in  neuralgia.  These  may  consist  in  subjective 
feelings  of  numbness  or  formication,  or  the  derange- 
ments of  sensibility  may  be  more  marked,  assuming 
the  form  of  anaesthesia  or  hyperesthesia.2  As  a  rule, 
these  phenomena  are  more  or  less  strictly  confined  to 
the  district  throughout  which  the  painful  nerve  is  dis- 
tributed. Neuralgic  affections  are  sometimes  accom- 
panied by  certain  reflex  phenomena,  which,  as  Eosen- 
thal  remarks,  may  be  explained  by  the  numerous 
communications  of  the  posterior  root-fibres  with  the 
gray  substance  of  the  cord.  Thus,  in  neuralgia  of  the 
limbs,  the  latter  are  subject  to  spasms  which  may  be 
local  or  diffuse  in  character  ;  while  in  facial  neuralgia 
sensory  irritation  gives  rise  to  muscular  contractions 
with  more  or  less  distortion  of  the  countenance. 

Vaso-motor  disturbances  are  frequently  met  with 
in  neuralgia.  These  may  consist  in  circulatory  disturb- 
ances, properly  speaking,  or  in  cutaneous  eruptions. 

trousseau's  "Clinical  Medicine,"  Vol.  I.,  London,  1868. 
2  "  Beitrag  zur  Lehre  von  der  Hyperesthesia  und  Anaesthesia, r 
von  L.  Tiirck,  Zeitschrift  d.  Grer.  der  Aerzte  zu  Wien,  1850. 
5 


CHAPTER  X. 

CLASSIFICATION   OF   NEURALGIA. 

(1).    TRIGEMINAL    NEURALGIA. 

In  most  of  the  books  it  is  the  custom  to  designate 
the  various  nerve-pains  according  to  the  nerve-stem  or 
branch  chiefly  implicated.  Thus  we  speak  of  trigemi 
nal  neuralgia,  supra-orbital  neuralgia,  etc.  Following 
this  well-established  precedent,  we  may  distinguish 
the  following  varieties  of  neuralgia: 

(1).  Trigeminal  Neuralgia  with  its  sub-varieties. 
(a).  Supra-orbital  (Ophthalmic)  Neuralgia. 
(b).  Supra-maxillary  (Infra-orbital)  Neuralgia. 
(c).  Infra-maxillary  Neuralgia. 

(2).  Cervico- Occipital  Neuralgia. 

(3).  Cervico- Brachial  Neuralgia. 

(4).  Crural  Neuralgia. 

(5).  Lumbar  Neuralgia. 

(6).  Lumbo-Abdominal  Neuralgia. 

(7).  Dorso-Intercostal  Neuralgia. 

(8).  Sciatic  Neuralgia. 

(9).  Plantar  Neuralgia. 
(10).  Coccygodynia. 
(11).  Mastodynia. 
(12).  Muscular  Neuralgia. 

In  the  foregoing  classification,  I  have  purposely 
omitted  the  visceral  pains,  as  their  origin  seems  still  too 
obscure  to  admit  of  final  classification.  I  may  add 
that  the  forms  of  nerve -pain  above  enumerated  are  of 
peculiar  interest  to  the  physician,  inasmuch  as  they 


CLASSIFICATION   OF  NEURALGIA.  67 

are  amenable  to  rational  treatment  of  a  local  character, 
owing  to  the  accessibility  of  the  nerve-stems  involved. 
Though  the  previous  general  survey  of  neuralgia 
affords  a  fair  conception  of  the  main  points  of  interest, 
as  far  as  the  symptomatology  is  concerned,  it  will  1  >e 
well  to  bestow  a  glance  upon  the  affection  as  mani- 
fested in  different  localities  of  the  body.  Following 
this  plan,  I  shall  adhere  strictly  to  the  classification 
of  nerve-pains  just  given,  as  it  is  at  once  simple  and 
sufficiently  comprehensive. 

TRIGEMINAL     NEURALGIA     (NEURALGIA     OF      THE     FIFTH 

NERVE). 

This  form  of  neuralgia  is  characterized  by  lightning- 
like  pains,  which  may  extend  throughout  the  entire 
area  supplied  by  the  fifth  nerve,  or  may  confine  itself  to 
one  or  more  branches  of  the  latter.  When  the  entire 
nerve  is  affected,  excruciating  pain  is  felt  throughout 
the  lateral  half  of  the  face  and  head.  Sometimes  these 
pains  assume  the  form  of  gnawing  sensations  more 
or  less  constant  in  character,  and  extending  through- 
out a  wide  area.  At  other  times  the  pains  resemble 
those  induced  by  the  electric  brush,  are  ambulatory 
and  intermittent,  and  are  referred  to  by  the  patient 
as  "  flying  about  "  or  "  shooting  through  the  head." 

The  painful  points  are  observed  at  the  localities 
where  the  nerve  emerges  from  a  bony  canal  or  pene- 
trates a  fascia.  As  in  other  forms  of  neuralgia  the 
painful  sensations  do  not  always  confine  themselves 
to  the  district  supplied  by  the  affected  nerve,  but  on 
the  contrary  they  are  projected  to  regions  more  or  less 
remote  from  the  primary  seat  of  the  affection. 

The  usual  vaso-  motor  disturbances  of  neuralgia  are 
observed  in  this  variety  of  the  affection  ;  they  consist 
in  pallor  and  coldness  of  the  skin  in  the  beginning  of 


68  HEADACHE  AND  NEURALGIA. 

the  attack,  which  speedily  give  place  to  a  red  cedema- 
tous  and  glassy  appearance  of  the  integument. 

In  former  writings  I  have  referred  at  some  length 
to  the  violent  pulsations  of  the  carotid  arteries,  espec- 
ially of  that  on  the  affected  side,  so  frequently  present 
in  neuralgia  of  the  face.  I  would  merely  ohserve,  in 
this  connection,  that  if  pressure  be  applied  with  skill 
to  these  arteries,  much  relief  may  sometimes  be  ob- 
tained from  the  distressing  pains.  The  methods  de- 
vised by  myself  for  executing  such  pressure  have 
already  been  described  in  the  previous  portion  of  this 
work.  It  must  not,  however,  be  imagined  that  per- 
manent relief  can  be  obtained  by  such  an  expedient ; 
for  experience  abundantly  teaches  that  a  cure  is  alone 
to  be  effected  by  the  inauguration  of  a  profound  change 
in  the  constitution  of  the  nerve  filaments  themselves. 
I  shall  refer  to  this  portion  of  the  subject  at  length  in 
the  chapters  on  treatment. 

It  is  not  surprising  that  with  such  profound  circula- 
tory disorders,  there  should  also  be  present  in  neural- 
gia derangements  of  considerable  magnitude.  These 
may  consist  in  the  first  instance  in  the  violent  swelling 
of  the  face,  already  referred  to,  erysipelas,  cutaneous 
eruption,  inflammation  of  the  periosteum,  iritis,  glau- 
coma, and  in  quite  exceptional  cases  in  neuroparalytic 
ophthalmia.  Where  the  affection  is  at  all  severe, 
motor  derangements  assuming  the  form  of  spasms  of 
the  muscles  of  the  mouth  or  eyelid  of  the  affected 
side  are  frequently  present. 

Great  mental  irritability  and  profound  depression  are 
almost  invariably  present  where  the  affection  is  severe 
and  has  lasted  for  some  time.  As  a  result  of  this  pro- 
tracted strain,  it  is  not  surprising  that  the  subject  may 
ultimately  be  completely  prostrated  or  even  driven  to 
suicide,  or  the  mad-house. 


CHAPTER  XI. 

TRIGEMINAL  NEURALGIA,   CONTINUED. 

MODIFICATION  IN  THE  SYMPTOMS  OF  FACIAL  NEURALGIA 
CONSEQUENT  UPON  THE  RESTRICTION  OF  THE  PAIX 
TO  ONE  OR  MORE  BRANCHES  OF  THE  NERVE. — CER- 
VICO-OCCIPITAL  NEURALGIA,  CERVICO  -  BRACHIAL 
NEURALGIA. 

As  already  observed,  the  pain  may  extend  through- 
out the  entire  territory  supplied  by  the  fifth  nerve,  or 
may  confine  itself  to  one  or  more  branches  of  the  same. 
One  of  the  most  frequent  of  these  sub-varieties  of  facial 
neuralgia  is  : 

(a).  Supra-orbital  or  Ophthalmic  Neuralgia. — In  this 
variety  of  the  affection  the  pain  is  located  in  the  fore- 
head, particularly  in  the  district  immediately  above 
the  affected  nerve.  The  upper  eyelid  is  also  usually 
painful.  As  in  the  other  forms  of  facial  neuralgia, 
there  is  lachrymation,  and  congestion  of  the  conjunc- 
tiva. Just  at  the  point  where  the  nerve  emerges 
through  the  supra-orbital  foramen  there  is  a  painful 
point  of  great  constancy.  This  variety  of  facial  neu- 
ralgia is  usually  traceable  to  malarial  influences.  The 
knowledge  of  this  fact  leads  many  physicians  to  pre- 
scribe large  doses  of  quinine  where  this  branch  of  the 
nerve  is  affected  ;  and  when  they  have  done  this,  they 
assume,  apparently,  that  their  duty  to  their  client  has 
been  fulfilled.  This  seems  to  me  poor  practice,  to  say 
the  least.     My  own  mode  of  dealing  with  such  cases 


TO  HEADACHE  AND  NEURALGIA. 

is  to  first  abolish  the  pain,  by  the  method  of  local 
medication,  which  I  shall  presently  describe,  and  then 
proceed  to  general  measures. 

(b).  Supra-maxillary  Neuralgia. —  In  those  cases 
where  all  the  branches  of  the  second  division  of  the 
fifth  nerve  are  involved,  the  pain  is  located  in  the  eye- 
lid, cheek,  nose,  upper  lip,  nasal  cavities  and  gums, 
upper  teeth,  and  in  the  zygomatic  arch  and  temporal 
region.  Sometimes,  however,  the  infra -orbital  branch 
of  the  second  division  of  the  nerve  is  alone  affected 
(infra- orbital  neuralgia).  Under  these  circumstances 
the  pain  is  felt  in  the  upper  lip,  cheek,  teeth  of  the 
upper  jaw  and  zygomatic  arch. 

The  painful  points  of  supra-maxillary  neuralgia  are 
located  where  the  nerve  leaves  the  skull ;  on  the  molar 
bone,  on  the  upper  lip,  and  in  rare  instances  on  the 
palate. 

(c).  Infra-maxillary  Neuralgia. — It  is  necessary  in 
considering  this  variety  of  neuralgia  to  differentiate 
sharply  between  a  complete  or  only  partial  implication 
of  the  third  division  of  the  fifth  nerve.  When  the 
entire  third  division  is  involved,  there  is  pain  in  the 
lower  teeth  and  lower  jaw,  in  the  raucous  membrane 
of  the  mouth,  in  the  tongue,  in  the  chin,  in  the  temple 
and  cheek,  and  in  the  external  auditory  meatus  and 
auricle  of  the  ear. 

The  more  important  painful  points  are  :  the  inferior 
dental,  situated  opposite  the  point  of  exit  of  the 
nerve  ;  the  temporal,  located  a  short  distance  in  front 
of  the  ear  •  the  parietal  point,  near  the  parietal  emi- 
nence ;  the  lingual,  on  the  side  of  the  tongue  ;  and  the 
inferior  labial.  When  only  a  portion  of  the  nerve  is 
affected,  the  pains  will  of  course  be  more  or  less  con- 
fined to  the  region  supplied  by  the  branch  of  the  nerve 
most  seriously  implicated. 


TRIGEMINAL  NEURALGIA.  71 

When,  in  facial  neuralgia,  the  pains  appear  in  rapid 
succession,  as  a  distinct  seizure,  lasting  a  few  seconds 
and  then  disappearing,  but  only  to  recur  after  a  shorter 
or  longer  interval,  we  speak  of  the  condition  as  epi- 
leptiform neuralgia.  This  is  one  of  the  most  atrocious 
varieties  of  pain  known  to  medicine,  and  is  usually 
developed  in  those  of  well-marked  neurotic  tendencies. 

(2.)   CERVICO-OCCIPITAL  NEURALGIA. 

As  a  rule,  the  pain  is  confined  to  the  region  supplied 
by  the  great  occipital  nerve.  The  patient  complains 
of  pains  in  the  occipital  and  posterior  parietal  regions, 
which,  in  exceptional  cases,  are  reflected  to  the  neck, 
brow,  cheek,  temple  or  inferior  portion  of  the  face, 
and  which  may  therefore  give  rise  to  the  supposition 
that  we  have  to  do  with  a  true  case  of  facial  neuralgia. 
A  careful  search  for  the  painful  points  will,  however, 
usually  serve  to  aid  in  the  formation  of  a  correct  diag- 
nosis. The  sensitive  points  are  usually  located  where 
the  nerve  approaches  most  nearly  the  surface,  but 
their  situation  is  subject  to  some  variation. 

(3.)   CERVICO-BRACHIAL  NEURALGIA. 

The  pain  in  cervico-brachial  neuralgia  is  perceived 
in  the  sub  clavicular  region,  throughout  the  course  of 
the  upper  extremity,  and  sometimes  in  the  breast. 
When  we  consider  that  the  five  lower  cervical  and 
first  dorsal  (brachial  plexus)  may  be  wholly  or  partially 
involved,  this  wide  distribution  of  the  pains  is  easily 
understood. 

When  the  plexus  is  only  partially  affected,  it  is 
difficult  to  determine  what  branches  of  the  plexus  or 
nerve -roots  are  especially  involved,  owing  to  the  man- 
ner in  which  the  nerves  are  interlaced. 


72  HEADACHE  AND  NEURALGIA. 

The  painful  points  are  quite  variable  ;  we  present  a 
few  of  them : — A  radial  point  at  the  lower  external 
aspect  of  the  fore-arm ;  an  ulnar  point  between  the 
olecranon  and  epitrochlea ;  a  median  cephalic  point, 
at  the  elbow ;  a  shoulder  point,  where  the  cutaneous 
branches  of  the  circumflex  pierce  the  deltoid  ;  an  ax- 
illary point,  corresponding  to  the  brachial  plexus. 

Eheumatism  and  injuries  are  the  chief  causes  of  this 
variety  of  neuralgia,  just  as  malaria  is  the  chief  source 
of  certain  phases  of  facial  neuralgia. 

I  have  been  thus  explicit  in  treating  of  the  neural- 
gias of  the  head,  face,  neck  and  fore-arm,  because  a 
proper  understanding  of  their  various  phases  is  often  of 
great  value  in  forming  a  correct  diagnosis,  particularly 
when  it  is  necessary  to  differentiate  between  pains  of 
intra-cranial  and  those  of  the  extra-cranial  origin.  As 
to  the  remaining  varieties  of  neuralgias,  I  shall  make 
short  work  of  them,  as  they  are  of  subordinate  im- 
portance in  a  treatise  of  this  character. 


CHAPTER  XII. 

OTHER  VARIETIES   OF   NEURALGIA. 

(4.)   CRURAL  NEURALGIA. 

In  this  variety  of  neuralgia,  the  pain  is  felt  along 
the  central  and  inner  portion  of  the  anterior  aspect  of 
the  thigh.  The  pain,  following  the  ramifications  of 
the  nerve,  may  also  extend  to  the  lower  portion  of 
the  limb. 

As  this  variety  of  neuralgia  is  not  very  common, 
little  need  be  said  of  it,  except  that  the  painful  points 
usually  met  with  are  situated  near  the  groin,  at  the 
inner  side  of  the  patella  and  in  the  vicinity  of  the 
ankle  joint. 

(5.)   LUMBAR  NEURALGIA. 

The  pain  is  located  in  the  loins,  and  may  involve 
any  or  all  of  the  first  four  pairs  of  lumbar  nerves. 

(6.)   LUMBO-ABDOMINAL   NEURALGIA. 

Besides  the  loins,  the  mons  veneris,  the  scrotum, 
and  notably  the  hypogastrium  are  the  seat  of  pain. 
In  the  more  extreme  cases,  the  gastric  and  sexual 
functions  may  exhibit  more  or  less  derangement,  mani- 
fested by  vomiting  and  involuntary  ejaculations  of 
seminal  fluid. 

The  most  constant  painful  points  are  those  located 
over  the  posterior  branches  of  the  affected  nerves, 


74  HEADACHE  AND  NEURALGIA. 

Other  points  are  given  in  the  books,  but  they  are  far 
from  constant. 

(7.)   DORSO-INTERCOSTAL  NEURALGIA. 

In  this  form  of  the  affection,  the  pain  is  located  in 
the  back  and  in  the  anterior  and  lateral  walls  of  the 
thorax.  When  the  pain  in  the  back  is  the  prominent 
symptom,  the  condition  is  popularly  known  as  lum- 
bago, and  it  is  assumed  that  the  pains  are  due  to  rheu- 
matic or  muscular  causes. 

In  severe  cases  all  attempts  to  bend  forward  or  back- 
ward are  accompanied  by  great  pain;  while,  where 
the  intercostal  pain  is  a  prominent  feature,  respiration 
is  likewise  difficult  and  painful.  The  most  constant 
painful  points  are  found  over  the  points  of  emergence 
of  the  sensory  nerves  from  the  intercostal  foramina. 
Where  the  nerves  are  most  superficially  located,  pain- 
ful points  may  likewise  be  found  in  most  cases. 

Neurotic  and  anaemic  persons  are  particularly  prone 
to  become  the  victims  of  this  variety  of  neuralgia. 
Thin-blooded  women,  especially  between  the  ages  of 
twenty-five  and  fifty,  are  subject  to  it. 

The  most  prolific  exciting  cause  is  exposure  to  cold 
and  damp. 

As  a  matter  of  course,  pains  of  this  character  may 
be  induced  by  neoplasms,  and  inflammatory  and  de- 
generative changes  involving  the  vertebrae. 

(8.)   SCIATIC   NEURALGIA. 

In  this  variety  of  neuralgia,  the  pain  follows  the  area 
of  distribution  of  the  sensory  filaments  of  the  great 
and  small  sciatic  nerves.  The  subject  complains  of 
intense  burning,  boring,  cutting  or  shooting  pains,  ex- 
tending from  the  gluteal  region  down  the  posterior 


OTHER   VARIETIES  OP  NEURALGIA.  ?5 

aspect  of  the  thigh  and  ankle  to  the  sole  of  the  foot. 
In  exceptional  cases  the  pain  may  be  confined  to  the 
gluteal  region. 

The  principal  painful  points  are  located  where  the 
nerves  emerge  from  the  pelvis ;  at  the  points  where 
the  cutaneous  nerves  pierce  the  fascia  ;  at  a  spot  lo- 
cated near  the  head  of  the  fibula ;  an  external  and  an 
internal  malleolar  point. 

A  debilitated  condition  of  the  system  from  fevers 
or  other  constitutional  causes,  constitutes  the  most 
important  predisposing  factor.  Among  the  exciting 
causes  may  be  mentioned  exposure  to  cold  or  damp- 
ness, and  various  pathological  conditions  of  the  pelvis, 
giving  rise  to  pressure  upon  the  sacral  plexus.  This 
affection  is  more  common  among  men  than  among 
women,  though  I  have  witnessed  several  cases  occur- 
ring among  the  latter,  as  the  result  of  debility  or  some 
form  of  uterine  displacement.  In  the  chapter  devoted 
to  the  treatment  of  neuralgia,  I  shall  have  something 
to  say  concerning  the  special  measures  to  be  adopted 
in  the  local  treatment  of  sciatica. 

(9.)   PLANTAR  NEURALGIA. 

This  form  of  neuralgia  is  characterized  by  intense 
pain  beginning  in  the  heel  or  great  toe,  and  extending 
throughout  the  sole  of  the  foot.  As  a  rule,  both  feet 
are  affected.  Associated  with  the  pain,  there  is  ex- 
treme  vascular  distension  and  redness  of  the  affected 
area.  Walking  increases  the  pain,  while  after  the 
subject  has  remained  in  the  recumbent  posture  for 
some  time,  the  symptoms  are  greatly  alleviated. 

Dr.  S.  Weir  Mitch 3ll  was  the  first  to  give  a  full  and 
accurate  description  of  this  affection. 

Probably  the  congestion  of  the  affected  area,  coupled 


76  Headache  and  neuralgia. 

with  more  or  less  neuritis  of  the  plantar  nerves,  is  the 
true  cause  of  the  affection. 

The  affection  should  be  treated  by  bathing  the  feet 
in  solutions  of  carbolic  acid  of  sufficient  strength  to 
cause  exfoliation  of  the  plantar  epidermis  on  scraping 
with  an  ivory  paper  knife.  Subsequently  the  plantar 
nerves  should  be  medicated  locally  according  to  the 
method  which  I  shall  presently  indicate  in  the  chapter 
on  treatment.  While  the  patient  is  at  rest,  the  extrem- 
ities should  be  kept  somewhat  elevated.  This  is  best 
accomplished  by  elevating  slightly  the  foot  of  the  bed 
by  means  of  blocks  of  wood  of  a  thickness  of  from 
two  to  three  inches.  At  first  difficulty  in  sleeping 
will  be  experienced  by  the  patient,  but  this  is  soon 
overcome,  especially  if  a  relatively  high  pillow  be  em- 
ployed. 

(10.)   COCCYGODYNIA. 

This  term  has  been  applied  by  Scanzoni,  Erichsen, 
Simpson  and  others,  to  neuralgia  of  the  ramifications 
of  the  coccygeal  plexus. 

The  affection  manifests  itself  chiefly  by  severe  pain 
in  the  coccyx,  which  is  greatly  aggravated  by  sitting 
or  straining  at  stool.  Persons  afflicted  by  coccygody- 
nia  sit  upon  a  soft  cushion,  or  in  the  absence  of  the 
latter  upon  the  edge  of  the  chair. 

The  affection  is  particularly  prone  to  occur  in  women 
as  the  consequence  of  difficult  or  complicated  labor, 
or  as  the  result  of  some  uterine  derangement.  Injur- 
ies, inflammation  of  the  coccyx  or  its  ligamentous 
attachments,  caries  and  ankylosis  may  also  cause  it. 

The  treatment  of  this  form  of  pain  by  leeching, 
fomentations,  baths,  electricity  and  the  like,  is  at 
most  merely  palliative.  In  the  severer  cases,  relief 
must  be  sought  by  resort  to  surgery. 


OTHER   VARIETIES  OP  NEURALGIA.  71 

An  American  surgeon,  of  Alabama,  extirpated  the 
coccyx  in  1832  ; '  and  since  that  time  the  procedure  has 
been  frequently  resorted  to.  and  with  reason,  as  the 
chances  of  abolishing  the  pain  by  this  means  are  much 
greater  than  when  section  of  the  ligaments  and  mus- 
cles is  performed,  as  recommended  by  Simpson. 

(11.)   MASTODYNIA   ("IRRITABLE  BREAST  "). 

This  is  merely  a  variety  of  intercostal  neuralgia. 
The  predisposing  causes  are  the  same  as  those  of  other 
forms  of  neuralgia.  Among  the  exciting  causes  may 
be  mentioned  injuries  of  the  gland,  cracked  or 
shrunken  nipples,  and  tumors  which  press  upon  the 
nerves. 

The  painful  points  are  exceedingly  variable,  and 
are  therefore  of  little  practical  moment.  Spinal  ten- 
derness, especially  in  the  region  of  the  upper  dorsal 
vertebrae  is,  however,  fairly  constant. 

Where  the  cause  is  manifest,  it  should  be  removed 
as  speedily  as  possible  ;  and  meanwhile  the  patient 
should  be  relieved  by  the  administration  of  opiates. 

(12.)   MUSCULAR  NEURALGIA. 

Both  physician  and  patient  have  long  been  in  the 
habit  of  referring  certain  painful  sensations  to  the 
muscles.  The  muscles  most  frequently  involved  are 
those  of  the  back  and  neck ;  and  inasmuch  as  these 
muscle-pains  frequently  exist  quite  independent  of 
any  exaggeration  of  cutaneous  sensibility,  the  popular 
mode  of  regarding  them  as  due  to  an  abnormal  condi- 
tion of  muscular  sensibility  seems  justified. 

The  same  methods  of  treatment  to  which  resort  is 

1  "American  Journal  of  (ho  Medical  Sciences,"  III.,  1883. 


78  HEADACHE  AND  NEURALGIA. 

had  in  cutaneous  neuralgia,  may,  with  slight  modifica- 
tions, be  employed  in  combating  these  hypersesthetic 
conditions  of  the  muscles. 

These,  then,  are  the  varieties  of  neuralgia  most  fre- 
quently encountered  in  practice. 

In  the  succeeding  chapters,  I  shall  enter  into  a  con- 
sideration of  the  causation,  diagnosis,  pathology  and 
prognosis  of  neuralgia,  as  a  preliminary  to  the  discus- 
sion of  the  various  factors  involved  in  treatment. 
This  latter  portion  of  the  subject  is  evidently  of  the 
first  importance  ;  and  I  shall  therefore  offer  no  apology 
for  devoting  much  space  to  its  elucidation. 


CHAPTER  XIII. 

CAUSATION. 

There  is  no  doubt  that  hereditary  influences  occupy 
a  conspicuous  place  among  predisposing  causes.  As 
previously  observed,  those  who  have  received  from 
their  progenitors  sickly  constitutions  or  pronounced 
neurotic  tendencies  frequently  become  the  victims  of 
periodic  neuralgias.  This  liability  to  transmission, 
which  is  a  pronounced  characteristic  of  nervous  disor- 
ders in  general,  is  particularly  well  exemplified  in 
the  various  forms  of  mental  derangement. 

It  is  a  well-known  fact  that  in  those  diseases  the 
hereditary  taint  often  affects  the  mental  integrity  of 
many  generations  ;  comparatively  trivial  causes  being 
required  to  evoke  active  mental  alienation  in  individuals 
who  have  inherited  the  insane  diathesis.  A  similar 
state  of  things  is  often  observed  in  connection  with 
neuralgia.  Fathers  and  mothers  afflicted  with  neu- 
ralgia frequently  transmit  a  predisposition  to  this  or 
some  other  form  of  nervous  derangement  to  their 
offspring,  and  the  latter  in  their  turn  bequeath  the 
morbid  tendency  to  future  generations. 

The  most  severe  varieties  of  the  affection  are  ob- 
served among  those  in  whom  the  vital  forces  have 
been  greatly  curtailed  through  the  agency  of  wasting 
diseases  or  general  malnutrition.  Anstie '  has  assumed 
a  hereditary  weakness  of  the  ganglia  of  the  posterior 
columns,  which,  when  subjected  to  protracted  centri- 

1  "Neuralgia  and  Diseases  that  Resemble  It."    London,  1871. 


80  HEADACHE  AND  NEURALGIA. 

petal  irritation  becomes  the  seat  of  interstitial  atrophy. 
For  my  own  part,  I  cannot  accept  this  hypothesis, 
since  if  in  all  cases  of  neuralgia  such  a  serious  lesion 
were  present,  it  would  be  difficult  to  conceive  of  cures 
taking  place  at  all. 

As  is  well  known,  not  a  few  cases  of  the  affection 
yield  to  hyper-nutrition  and  local  treatment,  a  fact 
difficult  of  explanation,  if  a  positive  destruction  of 
nerve  cells  be  conceded  to  be  an  invariable  concom- 
itant of  the  affection.  Climatic  peculiarities  exercise 
a  marked  influence  upon  the  evolution  of  neuralgias. 
The  most  favorable  season  for  the  development  of  the 
affection  is  during  the  cold,  damp  months  of  the  year. 
Sudden  changes  in  temperature,  as  already  noted, 
are  particularly  prone  to  develop  an  invasion  of  the 
disease.  Exposure  to  cold  and  violent  winds,  as  well 
as  residence  in  damp,  dark,  and  badly  ventilated 
dwellings,  is  liable  to  cause  an  attack  of  neuralgia, 
which  has  a  marked  tendency  to  become  chronic,  un- 
less a  change  of  climate  be  immediately  sought. 

Previous  to  marriage,  females  are,  on  the  whole, 
more  liable  to  the  affection  than  men. 

The  neuralgias  which  frequently  follow  chronic 
pulmonary  affections,  chlorosis,  and  other  debilitating 
maladies,  are  the  result  of  inability  on  the  part  of  the 
vitiated  blood  to  adequately  nourish  the  peripheral 
and  central  nervous  system. 

The  characteristic  lancinating  pains  of  neuralgia 
are  often  observed  in  conjunction  with  disturbances 
of  the  central  as  well  as  peripheral  nervous  system. 
It  has  been  affirmed  that  certain  congestive  cerebral 
conditions  may  give  rise  to  neuralgia,  and  the  associa- 
tion of  the  disorder  with  tumors,  softening  or  sclerosis 
is  not  uncommon.  A  number  of  inflammatory  affec- 
tions of  the  cord  are  accompanied  at  the  outset  by 


Causation.  SI 

neuralgic  symptoms  ;  the  lancinating  pains  of  ataxia 
are  a  good  illustration  of  this.  It  is  probable  that  the 
dyscrasic  and  toxic  forms  of  neuralgia  owe  their  ex- 
istence to  the  effects  of  the  deleterious  substances  upou 
the  nerve  cells  of  the  posterior  columns.  At  all  events 
this  seems  a  more  plausible  supposition  than  the 
pathological  hypothesis  of  Anstie,  already  referred  to. 
The  peripheral  causes  are  those  which  most  concern 
us  here,  since  they  constitute  the  etiological  factor 
most  frequently  encountered  among  cases  commonly 
designated  as  neuralgia.  In  this  category  belong  :  (1.) 
causes  which,  acting  upon  the  periphery  of  the  nerve, 
cause  compression  of  the  latter.  Thus  caries  and 
periostitis  involving  the  foramina  of  bones,  through 
which  the  nerves  pass,  may  cause  a  sufficient  degree 
of  constriction  to  set  up  inflammation  of  the  neuri- 
lemma. (2.)  Rheumatic  influences,  affecting  the  nerve 
fibres  of  muscles  and  joints.  (3.)  Foreign  bodies  and 
growths,  such  as  syphilitic  gummata,  tumors  and 
aneurisms.  (4.)  Congestive  and  inflammatory  condi- 
tions of  nerve-sheaths.  (5.)  Finally  there  are  certain 
neuralgias  which  owe  their  origin  to  irradiation  and 
reflex  causes. 
6 


CHAPTER  XIV. 
DIAGNOSIS. 

The  proper  differentiation  of  the  central  from  the 
peripheral  varieties  of  the  affection  is  evidently  a  mat- 
ter of  consequence  from  a  prognostic  point  of  view. 
To  summarize  briefly  the  requisites  of  such  discrimi- 
nation, it  may  be  stated,  in  the  first  place,  that  where 
central  causes  are  susjDected  a  careful  analysis  of  the 
condition  of  the  brain  and  spinal  cord  should  be  under- 
taken, both  by  means  of  objective  observation  and 
interrogatories  addressed  to  the  patient  himself.  If 
we  thus,  for  example,  diagnosticate  with  reasonable 
certainty  hyperemia,  inflammation  or  softening  of 
the  brain  or  spinal  cord  associated  with  "neuralgi- 
form "  pains,  and  if,  at  the  same  time,  we  are  unable 
to  discover  any  defect  of  the  peripheral  nervous  ap- 
paratus, we  are  justified  in  concluding  that  the  central 
disorder  is  the  true  cause  of  the  pains,  which,  in  accor- 
dance with  the  laws  of  eccentric  projection,  are  referred 
to  the  periphery. 

When  frontal  headache,  reflex  contractions  of  the 
face,  with  lacerating  pains  along  the  course  of  certain 
nerves  and  hyperesthesia,  are  associated  with  well- 
marked  psychical  disturbances,  the  suspicion  that  the 
neuralgia  is  of  cerebral  origin  is  justified.  When 
facial  neuralgia  co-exists  with  ambulatory-pains  in 
the  limbs  and  neck,  associated  with  vertigo,  periodic 
headache,  convulsions,  evidence  of  neuroretenitis,  and 
paresis  of  various  cranial  nerves  and  eventual  paraly- 


DIAGNOSIS.  83 

sis  of  the  extremities,  we  have  presented  unmistakeable 
evidence  of  cerebral  tumor. 

The  symptoms  which  point  to  the  spinal  origin  of 
neuralgia  are  :  early  formication  in  the  toes  and  fin- 
gers, numbness,  sensations  of  cold,  periodic  rachialgia 
and  brachialgia,  lancinating  pains  along  the  course  of 
the  sciatic  nerve  with  cutaneous  hyperesthesia,  in- 
equality of  the  pupils,  diplopia,  irritation  of  the  sexual 
organs,  fatigue  on  slight  exertion,  extreme  excitability 
to  the  electric  currBiit  iu  certain  circumscribed  locali- 
ties, and  susceptibility  to  moisture  and  variations  of 
temperature. 


CHAPTER  XV. 

PATHOLOGY. 

The  older  pathologists  were  in  the  habit  of  describ- 
ing "scorbutic,"  "rheumatic,"  "scrofulous,"  and 
"  arthritic  "  forms  of  neuralgia.  Among  more  recent 
writers,  however,  it  has  become  fashionable  to  attrib- 
ute the  pain  experienced  in  these  and  certain  consti- 
tutional affections  to  secondary  causes,  such  as  disease 
of  the  blood-vessels,  congestion  or  inflammation  prop- 
agated to  neighboring  blood-vessels,1  etc. 

The  hysterical  variety  of  neuralgia  is  usually  charac- 
terized by  the  ambulatory  nature  and  variable  inten- 
sity of  the  pains,  which  usually  follow  upon  hysterical 
convulsions  or  violent  mental  excitement. 

The  agency  of  syphilis  in  the  production  of  the  af- 
fection has  long  been  recognized.  In  all  probability 
the  dyscrasia  is  capable  of  causing  the  characteristic 
neuralgic  pains  by  the  inauguration  of  changes  in  the 
central  or  peripheral  nervous  system  or  both.  Thus 
chronic  inflammatory  processes  located  in  the  blood- 
vessels and  connective  tissue  may  affect  the  cord 
and  peripheral  nerves  as  well,  thus  giving  rise  to 
neuralgiform  pains.  Or,  osteal  and  periosteal  dis- 
eases may  affect  the  peripheral  nerves  in  their  transit 
through  bony  foramina,  producing  constriction  or  in- 
flammation, and  thus  causing  violent  pains. 

In  a  comparatively  recent  publication,  Fournier2 

1  See  Article  by  Erb,  Ziemssen's  Cyclopedia,  Vol.  XI. 
2  Legons  sur  la  Syphilis,  1873. 


PATHOLOGY.  85 

has  drawn  attention  to  the  typical  varieties  of  neural- 
gia which  occur  in  women  during  the  secondary  period 
of  syphilis,  and  which  evince  a  marked  predilection 
for  the  supra-orbital  and  sciatic  nerves.  The  mucous 
membranes  of  the  stomach,  rectum,  urethra  and  intes- 
tine are  frequently  the  seat  of  neuralgiform  pains ; 
when  thus  situated  the  latter  usually  point  to  an  hys- 
teria or  central  affection. 

There  are  a  number  of  toxic  substances  which, 
when  introduced  into  the  system,  may  give  rise  to 
more  or  less  severe  neuralgic  affections.  In  this  cate- 
gory belong  lead,  copper,  and  mercury.  Persons  who 
have  contracted  syphilis,  and  who  have  subsequently 
become  thoroughly  mercurialized,  frequently  develop 
an  obstinate  form  of  neuralgia.  Alcohol  and  tobacco 
when  employed  to  excess  may  also  give  rise  to  neural- 
giform symptoms  ;  but  the  precise  manner  in  which 
these  toxic  agents  act  is  still,  to  a  considerable  extent, 
enveloped  in  obscurity. 

The  influence  exercised  by  lead  in  the  production  of 
neuralgic  affections  has  long  been  understood,  and 
hence  the  designation  lead  arthralgia,  lead  colic,  etc. 


CHAPTEK  XVI. 

PROGNOSIS. 

The  first  step  of  importance  in  predicting  with  rea- 
sonable probability  the  prospect  of  cure  in  neuralgia, 
is  an  accurate  determination  of  the  exciting  cause. 
Where  the  latter  consists  in  an  organic  affection  of 
the  brain  or  spinal  cord  the  prognosis  is  unfavorable, 
in  the  majority  of  cases ;  and  the  most  that  can  be 
obtained  is  a  temporary  alleviation  of  the  symptoms. 
The  same  may  be  said  of  those  cases  which  are  attrib- 
utable to  permanent  organic  changes  of  structures 
contiguous  to  nerve  stems.  Thus  the  neuralgic  affec- 
tions resulting  from  osteal  and  periosteal  diseases,  tu- 
mors and  remote  and  inaccessible  cicatrices  are  practi- 
cally incurable.  On  the  other  hand,  those  varieties 
of  the  affections  which  result  from  malaria  and  syphi- 
lis are  exceedingly  amenable  to  treatment,  and  the 
prospect  of  ultimate  recovery  in  such  cases  is  good. 

As  a  rule, then,  peripheral  neuralgias  offer  a  far  better 
prognosis  than  those  which  result  from  organic  affec- 
tions of  the  central  nervous  system.  When  the  source 
of  peripheral  irritation  has  been  removed  recovery 
usually  ensues  ;  but  it  is  hardly  necessary  to  draw  at- 
tention to  the  well-known  liability  to  relapse  which 
asserts  itself  when  the  patient  is  unduly  exposed  to 
sudden  variations  of  temperature.  The  prospects  of 
recovery  are  more  favorable  in  men  than  in  women. 
Moreover,  the  question  of  age  is  of  no  little  importance 
in  determining  the  prospects  of  recovery  ;  and  it  may 


PROGNOSIS.  s7 

be  stated  in  general  terras  that  the  prognosis  is  oecid- 
edly  better  among  the  young  than  in  those  of  advanced 
life. 

The  occurrence  of  atrophic  changes,  anaesthesia  or 
paralysis  in  the  course  of  the  affection  may  be  regarded 
as  a  sign  of  ill-omen  as  far  as  the  chances  of  ultimate 
recovery  are  concerned, 

Where  the  puncta  dolorosa  persist,  after  the  pain 
has  subsided,  the  prospect  of  a  relapse  is  greatly  in- 
creased. In  the  majority  of  cases  the  immediate  dan- 
ger to  life  may  be  regarded  as  nil.  Sometimes,  how- 
ever, where  the  general  constitution  is  feeble,  and 
where  the  symptoms  have  persisted  for  a  long  time, 
the  strength  of  the  subject  finally  gives  way,  and  death 
ensues  from  marasmus  or  some  intercurrent  affection. 

Neuralgia  in  its  most  severe  form  has  frequently 
been  the  cause  of  suicide  ;  a  case  of  this  kind  recently 
occurred  in  New  York  City.  Even  where  the  condition 
of  the  patient  is  not  so  desperate  these  atrocious  face- 
pains  necessarily  seriously  jeopardize  the  success  and 
happiness  of  their  unfortunate  victim  ;  and,  as  already 
intimated,  they  sometimes  cause  permanent  mental 
trouble. 


CHAPTER  XVII. 

TEEATMENT   IK   GENEEAL. 

As  a  matter  of  course,  it  is  of  importance  to  ascer- 
tain the  exciting  cause  in  each  case,  and,  by  the  re- 
moval of  the  same,  insure  a  permanent  cessation  of 
the  neuralgic  symptoms.  Unfortunately,  however,  the 
discovery  of  the  predisposing  cause  was  in  former 
times  a  much  easier  matter  of  attainment  than  the 
subsequent  removal  of  the  pain  when  it  had  once  be- 
come firmly  established  ;  this  at  least  was  the  case 
previous  to  the  discovery  of  the  analgesic  properties 
of  antipyren  and  cocaine,  and  the  methods  of  pro- 
longing the  action  of  the  latter  drug.  As  I  have 
devoted  considerable  time  and  study  to  the  devel- 
opment of  the  capabilities  of  the  last  mentioned 
remedy  in  the  treatment  of  painful  nervous  affec- 
tions, and  as,  moreover,  the  methods  which  I  have 
devised  enable  the  physician  to  accomplish  much 
with  exceedingly  small  doses  of  the  drug,  I  shall  pres- 
ently describe  at  length  the  various  features  involved 
in  this  mode  of  local  treatment.  Let  me  state,  how- 
ever, before  proceeding  further,  that  I  always  arrest 
the  local  pain  as  far  as  possible,  by  resort  to  those 
methods  of  local  medication,  before  seeking  to  remove 
the  more  remote  constitutional  causes. 

Thus  while  our  resources  must,  to  a  considerable 
degree,  be  directed  towards  the  local  symptoms,  we 
should  not  fail,  at  the  same  time,  to  combat  the  obvious 
predisposing  factors  as  far  as  possible,  especially  when 


TREATMENT    IN    GENERAL.  89 

the  latter  are  of  a  more  or  less  constitutional  character, 
and  consequently  proportionately  amenable  to  treat- 
ment. Thus,  in  consonance  with  these  views,  if  the 
subject,  in  conjunction  with  neuralgia  is  likewise  a 
sufferer  from  general  anaemia,  a  causal  relation  between 
the  two  diseases  may  be  assumed  to  exist,  and  accord- 
ingly energetic  constitutional  treatment  should  be  em- 
ployed in  conjunction  with  proper  local  medication. 
When  scrofulosis,  gout,  tuberculosis  and  syphilis  are 
found  associated  with  neuralgia,  appropriate  medicinal 
and  dietetic  measures  should  be  directed  against  the 
dyscrasic  condition,  and  reliance  should,  under  no 
circumstances,  be  entirely  placed  upon  local  symp- 
tomatic treatment.  Where  the  neuralgia  occurs  peri- 
odically and  its  appearance  is  demonstrably  associa- 
ted with  malarial  influences,  quinine  should  be  given 
in  large  doses. 

As  I  have  said,  however,  we  should  relieve  the  local 
pain  before  resorting  to  this  or  any  other  mode  of  con- 
stitutional treatment.  Sometimes  a  few  doses  of  qui- 
nine are  beneficial,  but  I  cannot  agree  with  a  well- 
known  writer,  that  such  brief  medication  is  sufficient 
to  cause  permanent  disappearance  of  the  pain-provok- 
ing condition.  In  the  majority  of  cases  it  is  well  to 
continue  the  use  of  the  drug  for  several  days  or  weeks. 

Even  when  the  malarial  condition  has  apparently 
yielded  to  treatment,  and  the  pains  have  ceased  to 
recur,  a  short  sojourn  in  a  malarious  district  is  quite 
sufficient  to  cause"  a  relapse.  If,  by  careful  scrutiny 
of  the  history  of  the  case,  it  be  possible  to  discover  a 
toxic  influence,  such  as  that  induced  by  the  introduc- 
tion of  lead,  mercury  or  alcohol  into  the  system,  ap- 
propriate means  should  be  employed  for  removing  the 
foreign  substance  from  the  economy. 

Among  the  less-complicated  causes  of  neuralgia  are 


90  HEADACHE  AND  NEURALGIA. 

wounds,  cicatrices,  the  presence  of  foreign  bodies  of 
various  kinds  and  the  mechanical  effects  produced 
by  the  compression  of  nerve-stems  by  impacted  fecal 
masses,  periostitis,  tumors  and  cicatricial  tissue  depos- 
ited as  a  result  of  previous  inflammatory  or  traumatic 
causes.  In  those  cases  which  are  directly  attributable 
to  rheumatic  causes,  good  results  are  obtainable  from 
the  employment  of  the  Turkish  or  vapor  baths;  but,  as 
a  rule,  not  much  is  to  be  gained  by  the  local  applica- 
tion of  blisters  and  sinapisms.  The  iodide  of  potassium 
may  also  be  given,  and  the  resort,  during  the  winter 
months,  to  a  mild  and  equable  climate,  will  often  prove 
of  considerable  benefit.  When  neuritis  can  be  clearly 
diagnosticated  as  the  exciting  cause  of  the  affection, 
derivation  by  means  of  the  bowels  and  skin  should 
be  employed,  and  resort  may  also  be  had  to  local  ap- 
plications of  cold  and  dry  or  wet  cups. 

Better  than  all  these,  however,  in  well-marked  neu- 
ritis, is  the  local  medication  of  the  nerve-filaments,  al- 
ready referred  to,  and  which  I  shall  presently  describe 
at  length. 

In  the  cases  which  owe  their  existence  to  a  primary 
organic  affection  of  the  brain  or  spinal  cord,  but  little 
of  permanent  good  can  be  anticipated  from  treatment. 
As  already  intimated,  treatment  in  such  cases  must 
of  necessity  be  addressed  more  or  less  directly  to  the 
symptoms  themselves,  and  above  all  to  the  problem 
of  attaining,  from  time  to  time  at  least,  a  temporary 
abatement  in  the  intensity  of  the  pains.  Electricity, 
hydrotherapy  and  the  various  opiates,  particularly 
antipyren — or,  if  absolutely  necessary,  morphia — are 
our  best  aids  under  the  circumstances. 

Among  the  various  remedies  which  have  been  em- 
ployed, with  a  view  to  combatting  pain  in  all  its  forms, 
and  particularly  severe  intra  or  extra-cranial  pain, 


TREATMENT   IN   GENERAL.  91 

not  one  is  more  deserving  of  our  confidence  than  anti- 
pyren. At  the  meeting  of  the  Academie  de  Medicine 
at  Paris  on  the  23d  of  August,  1887,  M.  Germain  See 
drew  attention  to  the  valuable  analgesic  quality  of 
this  drug,  especially  in  headache,  migraine  and  face- 
ache.  The  cases  which  he  presented  on  this  occasion 
showed  in  a  striking  maimer  the  potency  of  this  re- 
markable drug  to  relieve  suffering.1 

Subsequently  this  gifted  clinician  showed "  how  pow- 
erful are  the  analgesic  effects  of  this  remedy  in  acute 
and  chronic  articular  rheumatism. 

This  is  not  the  place  to  enter  into  a  protracted  dis- 
cussion of  the  physiological  effects  of  the  remedy. 
Enough,  that  we  have  seen  M.  See's  statements  con- 
firmed again  and  again,  so  that  at  the  present  time 
it  would  be  difficult  to  find  a  practitioner  who  has  not 
had  occasion  to  endorse  to  a  great  extent  that  which 
has  beeu  affirmed  for  this  admirable  remedy  as  an 
antidote  to  pain  in  many  of  its  phases. 

For  my  own  part,  I  would  merely  state  that  I  have 
used  antipyren  not  only  in  all  forms  of  intra  and 
extra- cranial  pain,  but  in  spinal  irritation  and  spinal 
concussion  as  well,  with  excellent  results,  and  more 
particularly  when  given  in  conjunction  with  local  ex- 
pedients, such  as  injections,  refrigeration  and  the  like. 
I  have  also  witnessed  most  striking  results  from  its 
use  when  combined  with  relatively  minute  doses  of 
morphine. 

This  experience  with  the  remedy  has  confirmed  the 
belief  that  in  antipyren  we  have  one  of  the  most  val- 
uable, and  at  the  same  time  safe,  drugs  ever  introduced 


1  i1 Union  Medicate,  Troisieme  Serie,  Vol.  XLIV.,  page  273,  et 
seq.,  1887. 
2 17 'Union  Medicale,  Troisieme,  Serie,  Vol.  XLIV.,  p.  349,  1887. 


92  HEADACHE  AND  NEURALGIA. 

to  the  profession.  I  shall  have  occasion  to  refer  to 
this  useful  drug  hereafter. 

Having  said  this  much  in  a  general  way  regarding 
the  points  to  be  kept  in  view  in  any  rational  system 
of  therapeutics,  it  now  remains  to  describe  the  methods 
by  which  it  is  possible  to  submit  the  painful  nerve 
and  its  branches  to  the  action  of  various  potent  reme- 
dies, such  as  cocaine,  pyrogallic  acid,  aconite,  etc. 

From  my  own  experience,  as  well  as  from  that  of 
other  physicians  who  have  occupied  themselves  with 
the  subject,  I  cannot  help  feeling  that  this  mode  of 
treatment  constitutes  one  of  the  most  powerful  means 
at  our  disposal  for  directly  combatting  these  neuralgias 
of  the  face,  whatever  their  remote  origin  may  be. 

To  the  end  that  the  various  details  involved  in  this 
mode  of  neural  medication  may  be  the  better  under- 
stood,  I  shall  preface  the  description  of  the  individual 
steps  of  the  procedure  by  a  few  considerations  of  a 
somewhat  general  character. 


CHAPTER  XVIII. 

LOCAL  MEDICATION  OF  NERVES. 

OF   REMEDIES  WHICH   ARE   ADAPTED  TO   THE   MEDICATION 
OF  NERVES. 

It  is  not  my  intention  on  the  present  occasion  to 
enter  into  an  extended  discussion  of  the  intricate  phar- 
maco-dynamical  questions  involved  in  the  treatment 
of  affections  of  the  peripheral  nerves. 

To  do  this  would  presuppose  an  intimate  knowledge 
of  the  chemical  constitution  of  nerve  tissue  ;  and  such 
knowledge  is,  in  the  present  state  of  medical  science, 
denied  us.  While  we  cannot,  therefore,  know  what 
chemical  reactions  are  produced  by  the  contact  of  a 
given  medicament  with  the  substance  of  a  nerve,  we 
can  at  least  take  cognizance  of  any  considerable 
modification  in  the  function  of  the  latter  thereby  in- 
duced. 

Adopting  this  mode  of  regarding  the  question,  we 
find  that,  with  the  remedies  and  methods  at  our  dis- 
posal, we  are  able  to  accomplish  three  things.  We 
may  temporarily  suspend  the  conduction  in  a  nerve  ; 
or  we  may  change  its  constitution  to  such  a  degree  as 
to  more  or  less  permanently  interfere  with  the  trans- 
mission of  impression  through  the  same,  or  finally  we 
may  destroy  the  nerve  filaments  altogether.  The  first 
problem  is  best  accomplished  by  the  use  of  cocaine  ; 
the  second  by  the  application  of  chloroform  or  ether, 
immediately  after  the  cocainization  of  the  nerve,  or 


9-i  HEADACHE   AND   NEURALGIA. 

by  mechanical  aids  for  a  certain  length  of  time,  and 
the  last  by  the  use  of  acids  or  the  knife. 

The  first  mode  of  procedure  is  that  which  I  prefer  in 
cases  of  moderately  acute  nerve-pain,  reserving  the 
second  method  for  exceptionally  obstinate  and  chronic 
cases.  As  to  the  last  method,  it  should  not  be  resorted 
to  except  in  exceptional  cases. 

It  will  therefore  be  my  object  on  the  present  occa- 
sion to  show  first  how  remedies  may  be  best  introduced 
into  the  immediate  vicinity  of  painful  nerves,  and 
how  their  benignant  action  upon  the  latter  may  be  per- 
petuated. 

METHOD   OP  INTRODUCING  COCAINE   INTO  THE  SKIN  ABOUT 
THE   FACE. 

First  of  all  it  is  necessary  to  ascertain  what  branch 
or  branches  of  the  fifth  nerve  are  affected.  To  this 
end  the  patient  should  be  carefully  interrogated  as  to 
where  the  painful  sensations  are  located,  and  after- 
ward a  careful  digital  exploration  undertaken  by  the 
physician,  with  a  view  to  discovering  any  painful  points 
in  the  continuity  of  the  nerve-stems  which  may  serve 
as  a  guide  to  a  more  accurate  diagnosis. 

Having  thus  determined  what  are  the  offending 
branches  of  the  nerve,  it  only  remains  to  introduce 
the  medicament  into  the  painful  territory.  This  may 
be  accomplished  with  great  ease  and  accuracy  about 
the  face,  on  account  of  the  superficial  location  of  the 
sensory  nerves.  Moreover,  by  the  aid  of  the  method 
which  I  am  about  to  indicate,  it  may  be  achieved  ab- 
solutely without  pain  or  inconvenience  to  the  patient. 

The  procedure,  then,  which  I  have  found  effective 
for  the  purpose  is   as  follows  : ' —  The   region   to   be 

1  "New  York  Medical  Journal,"  Vol.  XLIV.,  Nov.  19,  1886.    See 


LOCAL  MEDICATION  OP  NERVES.  95 

anaesthetized  is  first  perforated  by  means  of  a  delicate 
instrument  provided  with  a  large  number  of  fine  nee- 
dles. There  is  no  pain  in  the  simple  manipulation,  as 
the  needles,  being  released,  are  driven  into  the  skin  so 
quickly  that  there  is  no  sensation  whatever.  Again, 
it  is  necessary  to  allow  the  needles  to  penetrate  be- 
yond the  epidermis. 

Having  thus  increased  the  porosity  of  the  skin  so 
as  to  admit  of  the  passage  of  the  medicament  into 
its  deeper  layers,  it  only  remains  to  introduce  the  same 
as  speedily  as  possible.  This  is  best  accomplished  by  the 
aid  of  the  galvanic  current.  A  sponge  electrode,  satu- 
rated with  a  solution  of  cocaine  of  appropriate  strength 
(5$),  is  secured  by  means  of  an  elastic  band  over  the  per- 
forated territory.  This  electrode  is  then  attached  by 
means  of  a  reophore  to  the  positive  pole  of  a  galvanic 
battery.  A  similar  electrode  saturated  with  warm 
water  is  secured  as  near  as  possible  to  the  first  sponge, 
but  without  touching  it,  and  is  then  comiected  with  the 
negative  pole  of  the  battery  by  an  appropriate  conduct- 
ing cord.  It  now  only  remains  to  so  regulate  the 
switch  board  that  from  four  to  six  cells  are  brought  into 
operation.  As  for  myself.  I  usually  begin  with  three 
cells,  gradually  increasing  the  strength  of  the  current 
until  five  or  six  cells  are  brought  into  requisition. 
By  adopting  this  policy  there  is  no  inconvenience  from 
the  action  of  the  current,  unless  a  slight  acid  taste  can 
be  described  as  such. 

also  Webster,   David,   M.  D.,   on  Coming's  method,  "Medical 
Record,"  March  5th,  1887. 

Benjamin  Richardson,  of  London,  was  the  first,  so  far  as  I 
know,  to  induce  local  anaesthesia  by  the  use  of  a  chemical  in 
conjunction  with  a  galvanic  current.  Subsequently  Wagner 
employed  the  same  method  in  conjunction  |with  cocaine.  I  im- 
proved Richardson's  procedure  by  introducing  the  principle  of 
preliminary  painless  puncture  of  the  skin. 


96  HEADACHE  AND  NEURALGIA. 

It  is  quite  impossible  to  lay  down  infallible  rules  as 
to  the  length  of  time  which  it  is  expedient  to  allow 
the  current  to  operate,  since  much  must  depend  upon 
the  strength  of  the  battery  and  the  extent  of  the  terri- 
tory which  it  is  desired  to  medicate.  At  all  events  ten, 
or  at  most  twenty  minutes  will  usually  be  sufficient ; 
and  should  the  pain  not  yet  have  subsided,  a  supple- 
mentary injection  of  a  three -per-cent  solution  of  the 
remedy  may  be  resorted  to.  As  a  rule,  however,  the 
pain  will  be  found  to  have  left  the  part  after  the  cur- 
rent has  operated  for  eight  or  ten  minutes. 

The  prolongation  of  the  action  of  the  medicament 
is  of  great  importance  in  the  treatment  of  neuralgia, 
as  we  are  thereby  enabled  to  expose  the  affected  nerve 
filament  for  a  long  time  to  the  influence  of  the  remedy. 
That  the  chemical  action  of  the  latter  upon  the  painful 
nerve  filaments  is  thereby  immeasurably  increased, 
is  beyond  question.  This  prolongation  of  the  effects 
of  the  remedy  may  be  accomplished  in  a  twofold 
manner,  to  wit :  (1.)  By  the  employment  of  certain 
mechanical  appliances,  and  (2.)  by  resort  to  certain 
potent  chemical  agents,  (chloroform,  acids,  ether,  etc., 
etc.)  I  shall  describe  at  once  the  first  (mechanical) 
mode  of  procedure,  as  it  is  at  once  simple  and  effi- 
cacious. 


CHAPTER  XIX. 
LOCAL  MEDICATION   OF   NERVES,   CONTINUED. 

THE  PROLONGATION  OF  THE  LOCAL  ACTION  OF  THE 
REMEDY.— AUTHOR'S  METHOD. 

When  cocaine  is  employed  about  the  extremities  it 
is  an  easy  matter  to  perpetuate  its  action  to  any  rea- 
sonable extent.  We  have  only,  in  fact,  to  suspend 
the  action  of  the  arterial  and  venous  circulation,  as  I 
have  long  since  shown  1  by  the  aid  of  an  appropriate 
bandage.  By  this  simple  means  we  are  enabled  to  keep 
the  anaesthetic  for  any  reasonable  time  in  contact  with 
the  nerve  filaments  :  for,  the  circulation  in  the  part 
being  suspended,  the  blood  cannot  wash  away  the  an- 
aesthetic into  the  general  circulation.  Likewise,  about 
the  breast  and  back,  we  can  accomplish,  though  in  a 
much  more  imperfect  manner,  a  similar  condition  of 
affairs  by  resorting  to  compression  by  the  aid  of  rings, 
clamps  and  the  like.  When,  however,  we  desire  to 
perpetuate  the  action  of  the  drug  about  the  face  the 
problem  is  wholly  different,  since  these  mechanical 
devices  are  not  available.  To  meet  this  difficulty  I 
have  devised  the  following  mode  of  procedure  : 2 

1  See  also  Wyeth,  John  A.,  on  Coming's  method  of  inducing 
cocaine  ansethesia  ("A  Text-book  on  Surgery,"  New  York,  1887, 
p.  22.)  Also  Smith,  Stephen,  on  Coming's  method,  "Principles 
and  Practice  of  Surgery,"  Philadelphia,  1887,  p.  54  et  seq.  See 
other  communications  on  the  same  subject  by  J.  R.  Conway,  J. 
Williston  Wright,  Robert  F.  Weir,  M.  J.  Roberts,  and  others. 

2  "The  Medication  of  Nerves,  and  its  Application  in  Treatment 

7 


98  HEADACHE  AND  NEURALGIA. 

Having  introduced  the  anaesthetic  throughout  the 
painful  territory,  according  to  the  method  previously 
described,  I  place  over  the  part  a  piece  of  fine  wire 
gauze  (Fig.  V.),  which  is  trimmed  with  a  pair  of  scis- 
sors so  as  to  exactly  cover  the  medicated  zone.  A 
T-shaped  block  of  wood  is  then  placed  upon  the  wire 
gauze,  and  a  considerable  degree  of  pressure  applied, 
by  means  of  an  elastic  strap  which  encircles  the  head 
and  is  secured  in  place  by  means  of  a  buckle  (Fig.  VI.). 
As  a  result  of  this  procedure  the  wire  gauze  is  pressed 
well  into  the  skin,  and  the  septa  of  the  same  cause  oc- 
clusion of  the  subjacent  capillaries,  but  without  press- 
ing out  the  cocaine,  which  remains  caught,  as  it  were, 
in  the  meshes  of  the  wire  gauze.  By  this  method  I 
have  often  produced  a  state  of  complete  anaesthesia 
lasting  an  hour  and  a  half.  It  is  not  surprising,  there- 
fore, that  such  a  protracted  exposure  of  the  nerve  fila- 
ments to  the  chemical  influence  of  the  drug  should 
often  of  itself  result  in  a  permanent  abolition  of  the 
painful  sensations.  Where  the  pain  is  located  above 
the  eyes,  as  in  supra-orbital  neuralgia  or  in  the  temple, 
this  mode  of  treatment  acts  like  magic. 

A  slight  modification  in  the  mode  of  procedure  is 
necessary,  especially  in  emaciated  subjects,  when  the 
pain  is  more  diffuse,  extending  to  the  cheeks  and  lower 
portion  of  the  face.  Under  these  circumstances,  I  am 
in  the  habit  of  first  tamponing  the  cheek,  which  is 
readily  accomplished  by  packing  the  face  between  the 
alveolar  processes  and  the  cheek  with  small  pledgets  of 
cotton.  The  cheek  being  thus  distended,  it  is  easy  to 
press  the  wire  gauze  upon  the  skin  with  sufficient 
force  to  cause  occlusion  of  the  subjacent  capillaries. 

of  Neuralgia  and  other  Painful  Affections."  A  paper  read  before 
the  Medical  Society  of  the  State  of  New  York,  Feb.  1st,  1887. 
Published  in  the  "Medical  Record  "  for  March  19th,  1887. 


LOCAL  MEDICATION  OF  NERVES,  CONTINUED. 


99 


I  can  truly  say  that  this  plan  of  treatment  has 
yielded  better  results  in  my  hands  than  I  have  been 
able  to  obtain  by  the  aid  of  that  polypharmacy  which 
has  been  so  fashionable  during  the  last  thirty  years. 

Sometimes,  in  uncomplicated  cases,  one  application 


HAZARD.  HAZARD.  KCO.W.F.FQRO 


Fig.  5. — Showing  the  kind  of  Wire  Gauze  to  be  Ejiployed. 


Fig.  6. — Showing  Application  of  Gauze  Block  and  Elastic  Strap,  for 
Relief  of  Pain  in  Temporal  Region. 


is  sufficient  to  abolish  the  pain  for  weeks  or  even 
months.  In  others,  again,  the  pain  may  return  after 
a  few  days,  but  with  less  intensity.  All  that  is  then 
necessary  is  to  repeat  the  procedure,  as  the  punctures 
are  so  small  as  to  leave  no  scars  behind,  hyperaemic 


100  HEADACHE  AND  NEURALGIA. 

spots  about  these  minute  openings  disappearing  within 
a  few  days,  as  already  observed.  Constitutional  treat- 
ment should  usually  be  continued  side  by  side  with 
these  local  measures,  so  that  the  nutritive  conditions 
of  the  organism  at  large  being  improved  the  affected 
nerve-stems  may  also  take  part  in  the  general  ame- 
lioration. 

I  will  merely  add  that  having  produced  an  anaes- 
thetic zone  of  the  desired  extent,  such  remedies  as 
chloroform,  ether,  aconite  and  pyrogallic  acid  may  be 
injected  without  the  slightest  pain  or  inconvenience. 
The  effects  of  these  remedies  upon  the  nerve-filaments 
may  then  be  prolonged  to  any  extent  by  the  applica- 
tion of  the  gauze,  block  and  strap. 

So  much  then  for  prolonged  local  medication  of  the 
nerves- — a  method  which  has  already  accomplished 
and  will  undoubtedly  continue  to  accomplish  much 
in  a  department  of  neurology  where  unfortunately  but 
little  of  practical  moment  has  heretofore  been  achieved. 

CASES. 

Although  an  extended  recapitulation  of  the  details 
of  the  clinic  would  be  a  work  of  evident  supereroga- 
tion in  a  monograph  of  this  character,  I  may  perhaps 
claim  the  indulgence  of  my  professional  readers  if  I 
take  the  liberty  of  citing  a  few  illustrations  of  the 
more  important  phases  of  neuralgic  pain. 

Let  us  begin,  then,  by  giving  the  principal  points  in 
some  cases  of  sciatica  which  I  have  treated  principally 
by  the  aid  of  local  measures. 

Before  proceeding  to  details,  however,  I  would 
again  call  to  mind  the  fact  that  three  years  ago  I 
brought  to  the  notice  of  the  profession1  certain  re- 

1  "New  York  Medical  Journal,"  Sept.  19th,  1885. 


LOCAL  MEDICATION  OF  NERVES,  CONTINUED.  L01 

searches  through  the  instrumentality  of  which  I  ascer- 
tained a  variety  of  facts  of  both  medical  and  surgical 
importance.  In  the  first  place,  I  conclusively  demon- 
strated that  the  suspension  of  the  arterial  and  venous 
circulation  in  a  part  into  which  such  an  anaesthetic 
as  cocaine  has  been  injected  is  sufficient  to  prolong 
the  anaesthetic  effect  for  any  length  of  time. 

Secondly,  I  showed  that  when  the  precaution  of  sus- 
pending the  circulation  has  been  observed,  it  is  no 
longer  necessary  to  employ  strong  solutions  of  the 
anaesthetic ;  but,  on  the  contrary,  the  strength  of  the 
latter  may  be  reduced  to  an  incredible  extent,  and 
yet  anaesthesia  of  the  part  be  induced  and  definitely 
protracted.  The  significance  of  these  facts  was  at 
once  appreciated  by  a  large  number  of  surgeons  ;  and 
soon  medical  literature  in  both  this  country  and 
Europe  began  to  teem  with  the  accounts  of  numer- 
ous operations,  more  or  less  extensive,  in  which  my 
method  of  inducing  local  anaesthesia  had  been  re- 
sorted to  with  excellent  results.  After  these  reports  of 
successful  operations  had  continued  to  appear  for  sev- 
eral months,  giving  rise  to  continuous  comments  both 
in  this  country  and  Europe,  I  decided  to  select  some 
of  the  more  noteworthy  of  these  cases,  and  to  embody 
the  same  in  book  form.  At  the  same  time  I  availed 
myself  of  the  opportunity  afforded  by  this  publication 
to  elaborate  the  technique  of  my  method,  so  as  to 
make  it  almost  universally  available.  ("  Local  Anaes- 
thesia," by  J.  Leonard  Corning,  M.  D.,  New  York:  D. 
Appleton  &  Co.  1886).  The  reception  by  the  medical 
press  and  the  subsequent  large  sale  of  this  book  have 
convinced  me  that  my  endeavors  in  the  cause  of  scien- 
tific medicine  have  been  amply  appreciated  by  my 
colleagues  in  the  profession.  All  this  is,  of  course, 
gratifying.     Still,  while  I  was  glad  to  have  rendered 


102  HEADACHE  AND  NEURALGIA. 

service  to  such  of  my  colleagues  as  are  engaged  in  the 
practice  of  surgery,  it  was  but  natural  that  the  desire 
should  have  been  rife,  in  one  interested  in  neurological 
medicine,  to  make  the  method  of  some  use  in  that 
branch  of  practice.  Indeed,  I  will  admit  at  once, 
that,  at  the  very  beginning  of  these  labors,  I  saw 
certain  possibilities  in  this  direction,  particularly  in 
the  treatment  of  derangements  of  the  peripheral 
nerves.  Thus,  in  my  original  paper,  I  said:  "In  the 
treatment  of  neuralgias,  and  other  disorders  of  the 
peripheral  nervous  system,  it  (my  method)  is,  I  believe, 
destined  to  render  good  service."  For  some  time 
these  scientific  anticipations  remained  without  fruit 
of  a  practical  nature  ;  for,  indeed,  my  professional  en- 
gagements had  been  such  that  I  was  unable  to  follow 
them  to  a  practical  sequence.  Some  time  since,  how- 
ever, I  was  able  to  put  these  ideas  to  a  practical  clini- 
cal test,  and  it  is  with  a  view  to  reporting  the  results 
more  fully  that  I  have  indulged  in  these  reminiscences. 

The  first  case  in  which  I  put  my  method  to  a  test 
was  one  of  sciatica  of  long  standing.  The  history  of 
the  case,  and  its  treatment  by  me,  is  briefly  as  follows  : 

B.  F.,  woman  of  45  years,  single,  of  feeble  neurotic 
temperament,  came  under  my  care  some  time  since. 
On  making  a  careful  examination,  I  found  the  follow- 
ing condition  of  things  :  She  had  long  suffered  from 
uterine  displacement,  caused,  as  I  was  informed,  by 
an  attempt  to  lift  the  end  of  an  upright  piano.  From 
this  time  forth  her  health  had  gradually  failed ;  she 
had  lost  flesh,  her  appetite  had  become  poor,  her  sleep, 
which  was  never  of  the  best,  had  deteriorated  to  such 
a  degree  that,  as  she  expressed  it,  she  was  "never 
wholly  unconscious,"  her  menstruation  was  painful 
and  irregular,  and  she  suffered  from  a  morbid  appre- 
hensiveness,  exhibiting  itself  in  a  dread  of  all  society 


LOCAL  MEDICATION  OP  NERVES,  CONTINUED.         103 

and  in  an  inability  to  sleep  without  a  light  in  her  bed- 
room. The  chief  cause  of  her  distress  was,  however, 
a  violent  neuralgia  of  the  right  sciatic  nerve,  which 
was  not  benefited  by  any  of  the  various  forms  of  uter- 
ine support.  From  this  she  had  suffered,  at  intervals, 
for  the  past  fifteen  months.  On  examination,  many 
painful  points  were  found  along  the  course  of  the 
nerve  ;  the  limb  was  maintained  in  a  partially  flexed 
condition  most  of  the  time  ;  there  was  considerable 
cutaneous  hyperesthesia,  but  no  anaesthesia  ;  the  pain, 
which  was  intense  during  the  day,  was  greatly  aggra- 
vated at  night,  and  the  mere  touch  of  the  bed-clothes 
was  often  sufficient  to  cause  an  intense  paroxysm ; 
the  affected  limb  was  pale  and  cold  to  the  touch,  the 
relative  difference  between  the  healthy  and  affected 
side  being  great. 

The  physician  under  whose  care  she  had  been  pre- 
vious to  consulting  me,  had,  very  justly,  as  it  then 
seemed  to  me,  attributed  the  sciatica  to  the  uterine 
displacement,  and  had  accordingly  applied  a  pessary. 
This  treatment  had,  however,  afforded  her  absolutely 
no  relief.  Subsequently  galvanism,  the  actual  cau- 
tery, blisters,  hot  and  cold  fomentations,  the  Turkish 
and  Eussian  baths  were  all  essayed,  but  without  any 
considerable  benefit. 

When  I  first  saw  her  she  was  suffering  from  a  par- 
oxysm of  unusual  severity,  so  that  short  periods  of 
sleep  were  only  obtainable  by  the  use  of  copious  mor- 
phine injections.  The  latter  were  made  over  the  pain- 
ful points  along  the  course  of  the  nerve ;  but  what 
little  relief  the  patient  thus  obtained  was  but  tempo- 
rary. All  usual  measures  having  failed,  I  finally  had 
recourse  to  the  following  procedure  : 

I  injected  one  hundred  minims  of  a  ^-solution  of 
cocaine  at  two  of  the  more  painful  points  along  the 


104  HEADACHE  AND  NEURALGIA. 

course  of  the  nerve,  and  immediately  thereafter  ap- 
plied a  tourniquet  in  such  wise  as  to  interrupt  the  cir- 
culation in  the  crural  artery,  above  the  point  of  injec- 
tion. As  a  rule,  I  believe,  the  tourniquet  should  be 
placed  as  high  up  as  possible.  In  this  case  it  was  lo- 
cated as  near  Poupart's  ligament  as  was  consistent 
with  the  retention  in  place  of  the  instrument. 

During  the  first  five  or  ten  minutes  little  relief  was 
experienced,  but  after  the  lapse  of  twenty  minutes  the 
pain  had  sensibly  diminished,  and  in  half  an  hour  it 
had  entirely  disappeared.  The  patient  complained 
somewhat  of  the  pressure  of  the  bandage,  but  this 
was  relieved  by  placing  a  small  roll  of  cotton  under 
the  tourniquet,  where  the  latter  passed  over  the  nerve- 
stem.  The  tourniquet  being  removed,  she  declared 
that  she  felt  no  pain,  even  after  the  lapse  of  eight  or 
nine  hours.  On  the  morning  following  the  treatment 
there  was,  however,  a  return  of  pain .  I  immediately 
made  the  injections  and  applied  the  bandage  as  before. 
This  time,  after  the  removal  of  the  tourniquet,  there 
was  no  return  of  pain  for  four  days.  Without  enter- 
ing further  into  details,  I  may  state  that  for  three 
weeks  this  mode  of  treatment  was  persisted  in,  the 
incarcerated  injections  being  resorted  to  whenever  there 
was  a  recurrence  of  pain.  The  periods  of  exemption 
became  longer  and  longer,  until  the  pain  finally  left 
her,  apparently  for  good.  It  is  now  four  months  since 
the  last  injection,  and  there  has  been  no  return  of  pain. 

The  second  case  in  which  I  resorted  to  this  method 
of  prolonged  medication  was  that  of  a  lady  of  sixty- 
five,  who  was  likewise  a  sufferer  from  sciatica  of  many 
years  standing.  In  her  case  the  usual  expedients  had 
been  resorted  to,  but  with  little  or  no  avail. 

As  in  the  previous  case,  I  made  copious  and  deep 
injections  of  solutions  of  the  hydrochlorate  of  cocaine, 


LOCAL  MEDICATION  OF  NERVES,  CONTINUED.         105 

incarcerating  the  medicament  by  the  application  of 
the  tourniquet  above  the  point  of  injection.  This  pro- 
longed contact  of  the  medicament  with  the  nerve-stem 
proved  almost  as  salutary  as  in  the  previous  case,  but, 
owing  to  the  long  continuance  of  the  painful  affection, 
treatment  was  more  prolonged.  Finally  the  tendency  to 
a  recurrence  of  the  painful  paroxysm  was  overcome. 
Three  months  have  now  elapsed  since  the  last  medication 
of  the  nerve,  and  there  has  been  no  return  of  the  pain. 

A  third  case  of  sciatica  in  a  man  of  fifty,  who  has 
been  under  my  care  for  the  past  two  months,  and  who 
has  been  treated  in  exactly  the  same  manner  as  the 
two  previous  cases,  exhibits  every  indication  of  even- 
tual complete  recovery. 

These  cases  have  aroused  in  my  mind  an  interesting 
train  of  reflections,  and  I  will  take  the  liberty  of  stat- 
ing briefly  some  of  the  conclusions  to  which  I  have 
been  unavoidably  conducted  : 

1.  That  this  method  of  subjecting  the  nerve  to  the 
prolonged  chemical  action  of  an  adjacent  medicament 
possesses  advantages  of  a  theoretical  and  practical  na- 
ture which  are  not  easily  over  estimated. 

2.  That  this  prolonged  medication  of  the  nerve,  by 
incarceration  of  the  medicament,  is  incomparably  more 
advantageous  than  the  ancient  expedient  of  simple 
injection,  without  incarceration  by  suspension  of  the 
circulation.  In  the  former  case  the  medicament  is 
held  in  contact  with  the  nerve  for  a  period  of  time, 
which  may  be  prolonged  at  the  discretion  of  the  phy- 
sician. In  the  latter  case  it  is  a  matter  of  extreme 
doubt  whether  the  nerve  is  influenced  to  any  appreci- 
able extent,  since  the  medicinal  solution  is  at  once  re- 
moved by  the  general  circulation,  and  has,  therefore, 
no  time  to  induce  the  requisite  chemical  changes  in 
the  nerve  filaments. 


IOC  HEADACHE  AND  NEURALGIA. 

3.  Solutions  of  low  percentage  (£#  or  \i)  should  be 
employed  for  prolonged  medication  of  nerves,  as  it  is 
thus  possible  to  inject  large  quantities  of  the  medica- 
ment without  danger  of  constitutional  symptoms.  It 
is,  moreover,  clear  that  the  prolonged  presence  of  this 
large  amount  of  fluid  in  the  neighborhood  of  the  nerve- 
stem  must  inevitably,  through  the  operation  of  imbibi- 
tion, profoundly  affect  the  nervous  filaments. 

4.  The  medicated  fluid  should  be  injected  as  near 
the  affected  nerve  as  possible  ;  but  care  should  be  ex- 
ercised not  to  wound  the  latter.  These  deep  injections 
may  be  accomplished  without  pain  by  injecting  a  small 
quantity  of  the  anaesthetic  before  the  point  of  the 
needle,  as  the  latter  is  propelled  into  the  tissues. 

5.  The  treatment  by  prolonged  medication  is  with- 
out danger,  and  therefore  superior  to  nerve-stretching 
by  the  surgical  method,  which  in  point  of  reliability 
leaves  much  to  be  desired. 

6.  Cocaine  is  only  one  of  many  fluids  which  may 
prove  useful  when  applied  according  to  this  method. 

These,  then,  are  some  of  the  conclusions  which  have 
forced  themselves  upon  me,  and  I  confidently  trust 
that  the  method  of  treatment  above  detailed  may  con- 
tinue to  yield  rich  results  in  the  hands  of  my  colleagues 
in  the  profession. 

It  would,  of  course,  be  possible  to  cite  many  cases  of 
sciatica,  in  which,  previous  to  perfecting  local  methods 
of  treatment,  I  had  resorted  to  such  conventional  re- 
sources as  the  actual  cautery,  the  constant  galvanic 
current,  blisters  and  the  like.  The  details  of  such 
cases  are,  however,  at  the  present  day  of  relatively 
little  interest,  and  I  therefore  pass  from  this  phase 
of  the  subject  to  the  consideration  of  some  of  the 
varieties  of  face-pain. 

Both  from  the  intensity  of  the  suffering  engendered, 


LOCAL  MEDICATION  OF  NERVES,  CONTINUED.  1"7 

as  well  as  from  the  frequency  of  its  occurrence,  facial 
neuralgia  is  pregnant  with  intense  practical  interest  to 
the  physician.  I  trust,  therefore,  that  a  case  or  two 
illustrating  some  of  the  phases  of  the  affection  as  well 
as  some  of  the  methods  of  treatment  elaborated  by 
myself  may  serve  a  useful  purpose, 

V.  C.  E.,  a  gentleman  fifty-seven  years  of  age,  was 
referred  to  me  by  Dr.  Cornelius  R.  Agnew,  on  account 
of  severe  supra  orbital  neuralgia.  There  is  a  distinct 
history  of  malaria,  which  the  patient  contracted  at  the 
South  several  years  since.  He  was  thoroughly  treated 
with  quinine  at  that  time  and  was  pronounced  "cured." 
Besides  the  supra-orbital  pain,  patient  is  frequently 
troubled  by  amblitory  pains  in  the  back  and  head, 
sometimes  accompanied  by  flashes  of  heat,  chills  and 
feelings  of  malaise.  All  ordinary  medication  having 
been  tried  without  avail,  I  put  the  patient  under  twenty- 
grain  doses  of  antipyren  three  times  a  day  in  conjunc- 
tion with  moderate  bromization.  In  this  way  the 
general  condition  was  much  improved,  and  the  pains 
about  the  head  (supra-orbital  and  occipital)  were  for 
the  time  completely  abolished.  The  supra- orbital  pain 
returned,  however,  shortly  after  discontinuance  of  the 
remedies.  On  making  a  critical  examination,  a  point 
of  extreme  tenderness  was  found  in  the  course  of  the 
nerve  ;  and  I  therefore  at  once  decided,  the  patisnt 
readily  consenting,  to  resort  to  local  medication  at  this 
point.  Having  carefully  marked  the  point  of  tender- 
ness with  iodine,  I  proceeded  to  cocainize  the  part,  ad- 
justing the  block  and  wire  gauze  as  already  described 
in  the  earlier  part  of  this  treatise.  Before  adjusting 
the  gauze,  however,  I  injected  two  drops  of  a  solution 
of  hydrocholoric  acid  of  a  considerable  degree  of  con- 
centration into  the  zone  of  tenderness  previously 
marked  with  the  iodine  stain.     The  block  and  gauze 


108  HEADACHE  AND  NEURALGIA. 

were  allowed  to  remain  in  place  three  quarters  of  an 
hour,  at  the  end  of  which  time  they  were  removed,  al- 
though the  anaesthetic  conditions  still  remained.  Three 
minutes  after  the  removal  of  the  gauze  the  anaesthesia 
began  to  abate,  and  five  minutes  thereafter  it  had  en- 
tirely disappeared.  In  its  place  there  was  a  feeling 
of  slight  soreness ;  but  the  characteristic  shooting 
pains  had  been  entirely  removed.  There  was  also  some 
swelling  of  the  tissues  at  the  seat  of  injection,  as  well 
as  slight  ecchymosis.  These  collateral  features  speed- 
ily disappeared  (at  the  end  of  a  week).  For  some  time 
longer  (three  or  four  weeks)  the  patient  remained  un- 
der my  care,  and  although  no  medication  other  than 
general  faradization  was  resorted  to,  there  was  not  the 
slightest-  return  of  pain,  nor  have  I  since  heard  of  any 
further  discomfort,  after  the  lapse  of  several  months. 
Such  a  result  as  this  speaks  for  itself;  no  more  graphic 
illustration  of  the  efficiency  of  the  treatment  adopted, 
where  the  pain  is  localized  in  a  given  nerve  tract,  could 
well  be  demanded. 

M.  M.  T.,  governess,  referred  to  me  by  Dr.  David 
Webster  for  supra- orbital  neuralgia.  About  two  years 
ago  patient  first  began  to  experience  pain  above  and 
around  the  left  eye.  Undue  tension  of  the  internal  rec- 
tus muscle  having  been  made  out  by  the  aid  of  prisms, 
Dr.  Agnew  decided  to  cut  that  muscle  with  a  view 
to  relieving  the  strain.  After  the  operation  there 
was,  I  believe,  some  relief  for  a  time  ;  but  the  pain 
returning,  she  was  referred  to  me  by  Dr.  David  Web- 
ster for  further  treatment.  On  examination,  I  found 
a  well-marked  point  of  sensitiveness  in  the  course  of 
the  supra-orbital  nerve.  As  the  patient  was  averse 
to  the  injection  of  remedies,  I  tried  all  ordinary  ex- 
pedients, such  as  galvanization,  counter  irritation  and 


LOCAL  MEDICATION  OP  NERVES,  CONTINUED.         109 

internal  remedies  of  various  kinds,  but  without  at- 
taining more  than  temporary  results. 

Finally,  by  dint  of  some  persuasion,  I  induced  the 
patient  to  consent  to  the  trial  of  local  medication.  Sen- 
sibility was  abolished  by  the  aid  of  the  local  anaesthetic, 
as  in  the  cases  previously  described.  An  injection  of 
TVth  of  a  grain  of  pyrogallic  acid  (pyrogalol)  was  then 
made  into  the  painful  spot,  and  the  gauze  and  block 
applied  for  three  quarters  of  an  hour  or  more. 

On  removing  the  gauze  the  usual  gridiron  appear- 
ance of  the  skin,  caused  by  the  pressure  of  the  gauze, 
was  present ;  and  shortly  afterwards  there  was  some 
swelling  of  the  part,  which,  however,  disappeared  en- 
tirely in  the  course  of  a  few  days.  The  slight  super- 
ficial soreness  which  almost  always  follows  this  plan 
of  treatment  also  speedily  subsided,  and  with  this 
restoration  there  was  a  concurrent  disappearance  of 
every  vestige  of  neuralgic  pain.  This  exemption  lasted 
until  the  famous  "  blizzard,"  when  the  patient  having 
contracted  a  severe  cold,  there  was  some  slight  return 
of  pain,  not  only  in  the  supra -orbital  region  but  in 
other  parts  of  the  face.  This  condition  was,  however, 
at  once  relieved  by  ten-grain  doses  of  antipyren,  which 
the  patient  was  nevertheless  obliged  to  discontinue 
on  account  of  her  extraordinary  susceptibility  to  the 
remedy.  In  her  case  even  five  grains  three  times  a 
day  wei'e  sufficient  to  cause  the  characteristic  rash. 

A  tendency  to  persistency  about  the  internal  can- 
thus  having  been  noted  in  this  second  painful  attack, 
I  decided  to  make  an  injection  into  the  painful  zone 
at  this  point.  Although,  in  this  instance,  it  was  im- 
possible to  apply  the  gauze  effectively,  I  succeeded 
nevertheless  in  arresting  the  pain,  as  I  trust  perma- 
nently, there  having  been  no  complaint  since. 

C.  0.  T.j  a  lady  of  sixty-three,  came  on  from  Green- 


110  HEADACHE  AND  NEURALGIA. 

field,  Mass.,  to  consult  me  for  a  severe  form  of  tic  dou- 
loureux, the  pain  being  located  in  a  circumscribed  spot, 
about  the  size  of  a  pea,  at  the  posterior  aspect  of  the 
upper  alveolar  process.  She  has  no  teeth  in  the  upper 
jaw,  and  the  gums  are  retracted  and  shrunken.  Every 
known  remedy  having  been  exhausted,  I  endeavored 
to  make  injections  into  the  painful  spot,  but  at  the 
first  attempt  the  hypodermic  needle  was  broken,  in  the 
endeavor  to  penetrate  the  hardened  gums.  A  second 
attempt  with  a  stronger  needle  resulted  more  fortu- 
nately, and  I  succeeded  in  depositing  about  ten  minims 
of  the  fluid  in  the  painful  region.  No  relief  whatever 
followed,  however,  owing  to  the  fact  that  the  medicinal 
fluid  was  not  taken  up  by  the  hat'dened  tissue. 

I  next  saw  the  patient  in  consultation  with  my  dis- 
tinguished friend,  the  late  Dr.  Theodore  R.  Varick, 
and  it  was  decided  to  loosen  the  gum  by  the  aid  of  the 
elevator.  This  was  accordingly  done  ;  but  the  result, 
as  before,  was  nil.  Had  the  patient  not  been  so  ad- 
vanced in  life,  I  should  have  advocated  extirpation  of 
the  nerve,  or  at  least  its  second  branch  ;  but  this,  under 
the  circumstances,  was  deemed  hazardous,  more  par- 
ticularly as  the  patient  was  in  a  state  of  debility. 

There  being  no  alternative,  I  put  this  good  lady  on 
whiskey,  and  insisted  upon  her  taking  it  in  sufficient 
quantities  to  deaden  the  painful  paroxysms,  of  which 
she  had  from  forty  to  fifty  attacks  a  day.  Later 
twenty-grain  doses  of  antipyren  four  times  a  day  were 
ordered,  in  conjunction  with  tonic  treatment  and  the 
local  application  of  steam  to  the  gums.  From  these 
latter  expedients  she  experienced  considerable  relief, 
but  I  was  never  able  to  wholly  break  up  the  attacks. 

This  case  is  instructive  as  offering  an  illustration  of 
a  class  of  cases,  in  which  I  have  been  unable  to  apply 
the  principle  of  local  medication  to  much  purpose. 


LOCAL  MEDICATION  OF  NERVES,  CONTINUED.  Ill 

I  now  desire  to  say  a  word  concerning  the  endermic 
use  of  remedies  in  neuralgia,  and  more  particularly  of 
the  application  of  pyrogalic  acid  and  cocaine  in  this 
manner. 

It  has  long  been  known  that  chemical  substances, 
particularly  in  solution,  when  brought  in  contact  with 
raw  surfaces  are  readily  absorbed.  Iodoform  and  car- 
bolic acid  poisoning,  as  the  sequence  of  too  copious  an 
application  of  these  substances  about  wounds,  afford 
familiar  illustration  of  the  principle  involved.  Like- 
wise, when  the  skin  is  denuded  of  its  epidermal  shield, 
it  becomes  at  once  pervious  to  substances  brought  in 
contact  with  it.  By  perviousness  of  the  skin  is  meant 
that  the  sub-epidermal  vessels  absorb  those  fluids 
which  are  brought  immediately  in  contact  with  them. 
Upon  the  facts  above  detailed  is  founded  what  is  known 
as  "  endermic  "  medication,  a  procedure  which  enjoyed 
considerable  popularity  in  the  profession  some  years 
ago.  So  far  as  I  am  aware,  cocaine  has  been  used  in 
this  way  to  but  a  limited  extent,  and  then  only  in  a 
primitive  fashion.  Without  claiming  any  great  credit 
for  originality,  but  guided  rather  by  the  desire  to  be 
of  some  slight  use  to  those  of  my  friends  who  may 
have  occasion  to  resort  to  local  anaesthesia  for  purely 
medical  purposes,  I  will  describe  briefly  the  method 
of  endermic  '  administration  which  I  have  found  most 
effective  :  I  first  remove  the  epidermis  by  the  aid  of 
vesicating  collodion  (Squibbs').  The  denuded  surface 
is  then  covered  with  an  india-rubber  membrane.  The 
size  of  the  membrane  should  be  such  that  its  edge 
projects  somewhat  beyond  the  raw  surface.  By  the 
aid  of  a  good  adhesive  preparation,  the  edges  (see  cut, 
C)  of  the  membrane  are  securely  glued  to  the  sur- 

1  First  described  by  me  in  the  "Journal  of  Surgery  and  Antisep- 
tics" for  January,  1888. 


112  Headache  and  neuralgia. 

rounding  unbroken  skin.  Should  the  adhesive  mater- 
ial prove  incapable  of  keeping  the  membrane  in  firm 
contact  with  the  skin,  a  ring  composed  of  thick  wire 
may  be  placed  upon  the  edges  of  the  membrane  and 
caused  to  exert  firm  pressure  upon  them  by  the  aid  of 
a  band.  As  an  additional  precaution  the  edge  of  the 
membrane  may  be  sealed  with  collodion. 

Through  a  metal  nipple,  provided  with  a  screw- 
cap,  and  situated  in  the  centre  of  the  india-rubber, 
cocaine  may  be  introduced  beneath  the  membrane.  I 
usually  employ  for  the  purpose  an  ordinary  medicine 
dropper.  Should  there  be  pain  in  the  part,  as  in  neu- 
ralgia, it  generally  disappears  in  a  relatively  short 
space  of  time — in  fact,  as  soon  as  a  certain  amount  of 
the  anaesthetic  has  been  absorbed. 

The  first  case  in  which  I  had  occasion  to  make  trial 
of  the  above  method  was  that  of  a  woman  who  had 
long  been  the  victim  of  neuralgic  attacks.  As  a  rule, 
the  pain  was  most  acutely  felt  about  the  temple,  ex- 
tending backward  toward  the  occiput,  and  this  was 
the  case  when  I  saw  her.  By  the  aid  of  vesicating 
collodion,  I  removed  the  epidermis  from  her  temple 
to  the  extent  of  a  space  about  the  size  of  a  quarter  of 
a  dollar.  Over  this  denuded  portion  of  the  skin  I 
stretched  the  india-rubber  membrane  and  secured  it 
in  place  as  above  described.  Fifty  minims  of  a  two- 
per-cent.  solution  of  the  hydrochlorate  of  cocaine  were 
then  placed  beneath  the  membrane  and  the  cap  screwed 
down.  Ten  minutes  later  the  pain  had  begun  to 
decrease,  and  twenty  minutes  thereafter  had  entirely 
disappeared.  In  spite  of  this  favorable  outcome,  I 
nevertheless  allowed  the  membrane  to  remain  in  place 
for  the  following  three  hours,  replenishing  the  anaes- 
thetic through  the  metallic  nipple  every  hour.  During 
this  time  there  was  entire  immunity  from  pain,  and, 


LOCAL  MEDICATION  OF  NERVES,  CONTINUED.    113 

so  far  as  one  can  perceive,  a  complete  cure  has  been 
effected.  But,  even  should  there  be  a  recurrence  of 
pain  at  some  future  time,  it  would  be  a  perfectly  easy 
and  proper  expedient  to  repeat  a  procedure  which 
has  already  yielded  so  good  a  result.  In  this  connec- 
tion, I  would  observe  that  the  greatest  care  should  be 
exercised  in  securing  the  membrane  to  the  skin,  so 
that  there  shall  be  no  leakage.  A  good  india-rubber 
adhesive  mass  is  the  best  substance  which  I  have  yet 
been  able  to  obtain;  but  I  am  in  hopes  of  finding 
something  still  better  in  the  course  of  time. 


The  second  case  in  which  I  tried  this  method, was 
one  in  which  there  was  localized  hypersesthesia  of  the 
fore -arm  subsequent  to  hemiplegia.  Throughout  a 
district  three  and  a  half  inches  long  by  two  in  breadth, 
the  epidermis  was  removed  at  regular  intervals  in 
pieces  about  the  size  of  a  pea;  so  that,  after  the  com- 
pletion of  the  operation,  the  skin  looked  somewhat  like 
a  sieve.  Over  this  district  the  rubber  membrane  was 
stretched  (see  cut):  and,  being  secured  as  before,  the 
anaesthetic  was  introduced  through  the  metal  nipple 
(A)  and  the  cap  screwed  on.     The  rubber  blister  (B) 


114  HEADACHE  AND  NEURALGIA. 

was  allowed  in  this  case  to  remain  in  place  for  two 
hours,  during  which  time  there  was  relief  from  all 
hyperaesthetic  symptoms.  On  the  following  day,  as 
there  was  a  return  of  the  abnormal  sensitiveness,  I  re- 
applied the  membrane,  being  careful,  however,  to  duly 
prepare  the  denuded  surfaces  beforehand,  as  follows: 

TOILET   OF   THE  DENUDED   SURFACES. 

Since,  after  the  lapse  of  several  hours,  there  is  an 
exudation  of  serum,  followed  by  the  formation  of  a 
firm  network  of  fibrin,  and  since  moreover  this  fibrin 
interferes  greatly  with  the  absorbent  qualities  of  the 
blistered  surface,  it  is  necessary  to  remove  the  same,  if 
the  denuded  surface  in  question  is  to  be  further  utili- 
zed. To  this  end,  I  am  in  the  habit  of  introducing 
through  the  metal  nipple  a  fine  camel's-hair  brush, 
saturated  with  a  diluted  solution  of  hydrochloric  acid, 
to  which  a  little  pepsin  has  been  added.  By  the  ap- 
plication of  this  solution  to  the  denuded  surfaces,  the 
fibrin  is  readily  dissolved,  the  healing  process  broken 
up  at  its  inception,  and  the  denuded  surfaces  placed 
once  more  in  a  receptive  condition. 

The  second  case  just  referred  to  is  hardly  a  fair  test 
of  the  permanency  of  the  effects  to  be  anticipated  from 
this  method  of  treatment,  though  it  abundantly  illus- 
trates the  correctness  of  the  principles  underlying  the 
procedure  itself. 

The  first  case,  on  the  contrary,  affords  a  good  illus- 
tration of  what  may  reasonably  be  anticipated  from 
this  mode  of  treatment  in  certain  phases  of  tic. 

I  trust  that,  in  giving  a  synopsis  of  the  above  cases, 
I  have  not  trespassed  too  much  upon  the  patience  of 
the  reader.  To  what  has  already  been  said,  I  desire 
merely  to  add  the  statement  that  when  the  pains  are 
diffuse  in  character,  the  painful  points  not  well  marked, 


LOCAL  MEDICATION  OF  NERVES,  CONTINUED.  115 

and  in  short  the  reflected  pains  lending  a  general 
character  to  the  affection,  antipyren  is  the  remedy  par 
excellence.  As  an  adjunct  of  great  value  to  all  forms 
of  local  treatment  it  is  also  of  the  greatest  possible  ad- 
vantage; and  the  physician  should  have  no  hesitancy 
in  thus  resorting  to  it. 


PART  III. 


HISTORICAL. 


CONSIDERATION  OP  METHODS  OP  TREAT- 
MENT HERETOFORE  PROPOSED. 


CAPTTER  XX. 

ELECTRICITY. 

It  now  remains  to  consider,  in  a  general  way,  and 
from  a  more  or  less  historical  standpoint,  a  number  of 
remedies  which  from  time  to  time  have  been  advo- 
cated by  various  writers  in  the  treatment  of  neuralgia. 
I  would  not  for  a  moment,  however,  have  the  reader 
imagine  that  I  myself  am  an  advocate  of  all  of  this 
polypharmacy.  From  what  has  already  been  said  it 
will  readily  be  perceived  that  I  entertain  quite  definite 
convictions  as  to  the  most  philosophical  method  of 
treating  this  painful  affection. 

At  the  same  time  I  deem  it  but  just  to  present  a 
general  survey  of  the  principal  points  which  have  char- 
acterized the  evolution  of  this  branch  of  therapeutics. 
If  the  brief  comments  which  I  shall  offer  thereupon 
from  time  to  time  are  often  tinctured  with  ill-disguised 
pessimism,  it  is  because  I  have  so  frequently  seen  many 
of  these  remedies  fail  utterly  both  in  my  own  practice 
and  in  the  hands  of  others. 

Among  the  more  prominent  remedies  employed  by 
modern  physicians,  none  has  given  rise  to  more  dis- 
cussion and  conflicting  testimony  than  Electricity. 
Both  the  galvanic,  the  induced  and  the  static  currents 
have  been  recommended.  When  the  continuous  gal- 
vanic current  is  employed  the  cathode  is  placed  upon 
the  sensitive  points,  while  the  anode  is  applied  as  closely 
as  possible  to  the  centres  (or  upon  the  sternum,  accord- 
ing to  some  authors). 


120  HEADACHE  AND  NEURALGIA. 

The  faradic  current  is  usually  employed  in  conjunc- 
tion with  the  wire  brush,  the  latter  being  directed 
along  the  course  of  the  affected  nerve-stems.  As 
regards  the  relative  value  of  the  two  currents  prefer- 
ence is  undoubtedly  to  be  given  to  the  galvanic,  on 
account  of  its  smaller  tension. 

Where  the  cause  of  the  disease  is  profoundly  located 
in  the  central  nervous  system  or  in  the  nerve-roots, 
the  galvanic  current  sometimes  proves  useful.  Again, 
when  a  powerful  ' '  catalytic ' '  effect  upon  nutrition  is 
desired,  the  galvanic  is  to  be  preferred  to  the  faradic 
current.  As  a  matter  of  course,  however,  little  per- 
manent good  can  be  hoped  for  in  those  cases  where 
the  affection  is  due  to  coarse  anatomical  changes  of  the 
brain  or  cord. 

On  the  other  hand,  in  the  idiopathic  varieties  of 
neuralgia — those  in  which  the  pains  are  traceable  to 
rheumatic  or  neuritic  causes  —  the  results  obtainable 
from  the  employment  of  the  galvanic  current  are  oc- 
casionally good.  Cures  are,  indeed,  sometimes  effected 
in  a  short  time;  but  such  cases  are  exceptional. 

The  testimony  of  a  large  number  of  neurologists 
bears  witness  to  the  value  of  electricity  in  certain 
phases  of  neuralgia;  it  cannot  be  said,  however,  that 
the  therapeutic  virtues  of  this  remedy  are  displayed  in 
all  phases  of  the  affection. 


CHAPTER  XXI. 

ELECTRICITY,    CONTINUED. — SIMULTANEOUS    APPLICATION 
OP    PRESSURE   AND   GALVANISM. 

Op  much  greater  value  than  the  application  of  gal- 
vanism alone  is  its  employment  in  conjunction  with 
a  considerable  degree  of  pressure  upon  the  affected 
nerve  filaments.  In  order  to  apply  mechanical  pres- 
sure, and  at  the  came  time  pass  the  current  through 
the  affected  nerve-stem,  I  have  had  constructed  the 
following  simple  device: 

A  strong  band  of  leather  provided  with  an  adjust- 
able buckle  is  transfixed  by  a  screw,  which  is  imbedded 
in  an  appropriately  constructed  metal  garniture.  One 
end  of  the  screw  is  ovoid  in  shape  and  is  covered  with 
chamois  skin,  thus  constituting  a  small  electrode.  To 
the  other  end  of  the  screw  is  secured  a  tran verse  cross- 
bar, which  serves  as  a  handle.  This  extremity  of  the 
screw  is  also  provided  with  an  appropriate  mechanism 
for  attaching  the  end  of  an  ordinary  conducting  cord. 

In  order  to  employ  the  apparatus,  the  strap  is  passed 
around  the  limb,  in  which  the  affected  nerve  is  located, 
and  secured  by  means  of  the  buckle.  The  ovoid  elec- 
trode is  then  placed  over  the  most  centrally  located 
painful  spot,  and  the  screw  is  rotated  until  as  much 
pressure  is  exercised  as  the  patient  can  endure.  In 
order  to  make  this  mode  of  treatment  more  comfort- 
able, I  have  recently  resorted  to  the  expedient  of 
making  superficial  and  deep  injections  of  cocaine  into 


122  HEADACHE  AND  NEURALGIA. 

the  part  before  applying  the  pad;  and  I  may  add  that 
I  have  found  this  a  most  useful  expedient,  especially 
in  the  treatment  of  sciatica.  To  continue  the  descrip- 
tion, the  pad  being  properly  adjusted,  the  disengaged 
end  of  the  screw  is  then  connected  with  the  positive 
pole  of  an  ordinary  galvanic  battery.  An  ordinary  flat 
sponge  electrode  is  then  secured  over  some  other  por- 
tion of  the  continuity  of  the  nerve  or  its  branches  by 
means  of  an  elastic  strap,  and  connected  with  the  neg- 
ative pole  of  the  battery.  Having  immersed  the  plates 
of  the  battery,  the  current  is  gradually  increased  until 
an  intense  burning  sensation  is  produced. 

The  first  sitting  should  be  brief  in  duration — from 
three  to  five  minutes;  but  upon  every  subsequent  oc- 
casion the  application  should  be  prolonged.  It  is  thus 
possible  to  progressively  increase  the  duration  of  the 
applications,  until  finally  from  fifteen  to  twenty  min- 
utes are  endured.  This,  however,  is  only  feasible  in 
those  cases  in  which  the  susceptibility  of  the  nerve- 
stem  to  pressure  and  to  the  influences  of  the  current 
becomes  gradually  less  acute.  Where  the  points  dou- 
loureux show  an  undue  tendency  to  persist,  only  short 
applications  of  from  three  to  five  minutes  at  a  time 
are  as  a  rule  possible.1 

For  making  prolonged  applications  about  the  cheeks, 
I  employ  a  clamp  electrode  (Fig.  IX),  which,  by  the 
rotation  of  a  screw  embraces  the  cheek  between  two 
sponges  (Fig.  X).  Each  sponge  is,  of  course,  con- 
nected by  a  conducting  cord  with  one  of  the  poles  of  a 
galvanic  battery.  By  a  simple  arrangement  a  consid- 
erably larger  external  sponge  than  the  one  seen  in  the 
cut  may  be  adjusted. 

1  In  old  cases  of  sciatica  and  tic  douloureux  I  have,  however, 
on  several  occasions  made  applications  lasting  from  half  to  three- 
quarters  of  an  hour,  and  even  longer,  with  excellent  results. 


ELECTRICITY,    CONTINUED. 


123 


I  have  also  employed  this  appliance  in  the  treatment 
of  facial  paralysis. ' 


Fig.  9. 


There  can   be  no  doubt    that  the  electric  current 
when  thus  employed,  modifies  the  abnormal  nutritive 


Fig.  10. 


conditions  of  nerves,  allays  persistent  hypersemic  and 
inflammatory  conditions,  and  thereby  diminishes  the 


1  "The  Medical  Register,"  May  5th,  1888,  page  413  et  seq. 


124:  HEADACHE   AND  NEURALGIA. 

excitability  of  the  sensory  nervous  system.  The  pre- 
cise  manner  in  which  these  beneficial  changes  are 
effected  must,  however,  remain  a  mystery  until  ex- 
perimental pathology  has  done  more  for  our  enlighten- 
ment. 


CHAPTER   XXII. 

NARCOTICS   AND   SEDATIVES. 

» 

The  second  class  of  remedies,  to  which  a  prominent 
place  must  be  assigned  in  the  treatment  of  painful 
affections,  constitutes  the  group  of  narcotics  and  anaes- 
thetics. Not  a  little  of  the  success  attending  the  em- 
ployment of  these  agents  is  attributable  to  the  improved 
methods  of  administration,  which  have  been  introduced 
during  the  last  few  years. 

Foremost  among  the  means  at  our  disposal  for  allay- 
ing pain  are  opium  and  its  alkaloids  The  researches 
of  Bernard  have  shown  that  opium  depresses  the  irri- 
tability of  the  sympathetic  system,  and  particularly 
that  portion  of  it  which  supplies  the  submaxillary 
gland.  The  first  effect  of  opium,  especially  when  ad- 
ministered in  small  doses,  is  to  increase  the  degree  of 
irritability;  but  the  primary  effects  soon  give  place  to 
well-marked  symptoms  of  depression. 

If  large  doses  be  given  at  once,  the  state  of  depres- 
sion is  developed  so  rapidly,  that  the  primary  stage  of 
irritability  is  evanescent  in  character  or  entirely  un- 
recognizable. 

These  facts  afford  a  substantial  basis  upon  which  to 
found  rational  rules  for  the  administration  of  the  drug. 
When  the  nervous  system  is  depressed,  as  in  various 
exhaustive  conditions  of  the  brain  and  cord,  the  re- 
medy should  be  given  in  small  doses,  in  order  to  obtain 
its  stimulating  effects;  but  when  the  irritability  of  the 
centres  and  peripheral  apparatus  is  unduly  increased, 


126  HEADACHE  AND  NEURALGIA. 

as  in  neuralgia  and  various  other  disorders,  it  should 
be  given  in  large  doses,  in  order  to  obtain  the  best 
results.  There  can  be  no  reasonable  doubt  that  much 
of  the  good  obtainable  from  the  use  of  narcotics  in 
painful  affections  is  attributable  to  the  benefits  arising 
from  increased  sleep,  during  which  trophic  and  irrita- 
tive disturbances  are  corrected.  This  aspect  of  the 
question  has,  up  to  the  present  time,  received  far  less 
attention  than  it  deserves. 

The  best  manner  of  administering  morphine,  the  al- 
kaloid of  opium,  which  of  late  years  has  obtained  such 
a  high  position  among  the  resources  of  the  pharmaco- 
poeia, is  by  the  means  of  the  hypodermic  syringe.  When 
it  is  desired  to  exert  a  more  or  less  general  effect  upon 
the  nervous  centres,  the  point  at  which  the  injection  is 
made  is  not  so  much  a  matter  of  consequence  as  where 
a  more  local  action  is  required.  Any  spot  about  the 
abdomen  or  arm,  where  the  skin  is  at  once  thin  and 
Irose,  and  where  there  are  few  veins,  will  do. 

It  is  usually  well  to  begin  with  a  dose  of  from  one- 
sixth  to  one  quarter  of  a  grain,  and  increase  the  same 
as  required.  When  the  effective  dose  has  been  ascer- 
tained, it  may  usually  be  employed  for  a  considerable 
period  without  material  increase.  By  degrees,  how- 
ever, the  system  becomes  habituated  to  the  remedy,  so 
that  in  the  course  of  time  it  becomes  imperatively 
necessary  to  increase  the  dose  in  order  to  obtain  the 
requisite  physiological  effects. 

It  is  well  known  to  most  physicians  that  the  injec- 
tion of  morphine  about  the  head  and  neck  may  some- 
times be  accompanied  by  transient  sensations  of 
faintness  and  anxiety,  and  even  by  confusion  of  ideas, 
sudden  drowsiness,  simulating  stupor  and  vomiting. 
These  symptoms  are  usually  devoid  of  any  ominous  sig- 
nificance, and  since  they  soon  pass  off, -no  particular 


NARCOTICS   AND   SEDATIVES.  127 

measures  for  their  removal  need  be  adopted.  More- 
over, if  the  patient  has  been  previously  apprised  of  the 
possibility  of  their  occurrence,  he  is  liable  to  experience 
no  undue  apprehension,  and  all  danger  from  the  effects 
of  sudden  fright  are  consequently  removed. 

As  a  rule  the  injection  is  not  required  above  once  or 
twice  a  day,  though  where  the  pains  are  unusually 
severe  the  operation  may  be  demanded  oftener.  Care 
should  always  be  exercised  to  give  the  remedy  as  in- 
frequently and  in  as  small  doses  as  possible,  with  a 
view  to  obviating  the  dangers  of  the  morphine  habit.  If 
we  succeed  in  suppressing  the  paroxysms  of  pain  for 
a  number  of  days  consecutively,  the  possibility  of 
eventual  cure  is  of  course  proportionately  enhanced. 

A  protracted  use  of  large  doses  of  morphine  has  the 
effect  of  thoroughly  habituating  the  patient  to  the 
drug,  so  that  the  system  not  only  thoroughly  accommo- 
dates itself  to  the  remedy  but  finally  craves  it  as  a 
physiological  requisite.  As  a  consequence  of  this  state 
of  things  it  is  impossible  to  suddenly  withdraw  the 
drug  from  those  long  accustomed  to  its  use,  without 
producing  a  series  of  irritating  and  even  dangerous 
symptoms.  When  thus  deprived  of  the  accustomed 
narcotic,  such  persons  become  weak,  irritable  and  lose 
flesh  rapidly,  and  if  not  sustained  by  copious  stimula- 
tion they  soon  succumb. 

For  my  own  part,  I  have  had  much  less  occasion  to 
resort  to  morphine  or  any  other  preparation  of  opium 
since  I  have  made  use  of  the  methods  of  local  medi- 
cation of  the  affected  nerve-stems  described  at  the  be- 
ginning of  the  section  on  treatment. 

This  ability  of  the  physician  to  dispense  in  a  measure 
with  the  aid  of  narcotics  is  not  the  least  advantage 
offered  by  this  mode  of  treatment. 

The  other  preparations  of  opium,  such  as  codeine, 


128  HEADACHE  AND  NEURALGIA. 

narcotine,  and  narceine  have  not  met  with  an  exten- 
sive employment  in  neuralgic  affections,  and  morphine 
must  still  be  regarded  as  the  most  important  alkaloid 
of  the  opium  group. 

Of  the  remaining  narcotics  atropine,  or  belladonna, 
is  worthy  of  special  consideration,  in  connection  with 
the  therapeutics  of  neuralgia.  The  action  of  this  drug 
is  powerful,  and  it  has  been  known  to  allay  pain  in 
cases  where  the  administration  of  morphia  has  been 
entirely  without  result.  Owing,  however,  to  its  ex- 
tremely poisonous  nature,  even  when  administered  in 
small  doses,  it  should  be  resorted  to  only  in  cases  where 
other  means  have  failed. 

Atropine  is  said  to  increase  the  irritability  of  the 
gray  substance  of  the  spinal  cord,  and  its  action  upon 
the  vaso-motor  and  respiratory  centres  is  particularly 
pronounced.  By  stimulating  the  centre  of  the  cardiac 
or  accelatory  nerve  it  acts  as  a  powerful  heart  tonic, 
and  Harley 1  has  recommended  it  in  this  connection. 

It  has  long  been  customary  to  employ  narcotics  in 
neuralgic  affections  in  the  form  of  various  ointments; 
but  of  recent  years  the  practice  has  been  more  or  less 
neglected.  An  explanation  for  this  is  found  in  the 
difficulty  experienced  in  causing  these  ointments  to 
penetrate  the  stratum  of  epidermal  cells.  I  have  found 
that  the  efficacy  of  all  such  preparations  is  greatly  en- 
hanced by  removing  the  superior  layer  of  dead  epider- 
mial  cells  before  applying  the  ointment.  Moreover, 
I  have  observed  that  if  the  skin  be  in  a  state  of  more 
or  less  congestion,  the  efficacy  of  the  ointment  is  cor- 
respondingly enhanced. 

Acting  upon  these  two  observations,  I  have  elabo- 
rated  the    following  method,  to    which  I  invariably 

1  Harley  on  the  Action  and  Uses  of  Belladonna,  Braitlvwaite's 
Retrospect,  Vol.  LVIL,  1868. 


NARCOTICS   AND   SEDATIVES.  129 

resort  where  it  is  desirable  to  utilize  the  soothing  prop- 
erties of  narcotic  ointments  to  the  fullest  extent. 
,  With  a  piece  of  ordinary  window  glass,  the  superficial 
strata  of  epidermal  cells  above  the  affected  part,  are 
carefully  removed  by  scraping.  A  series  of  dry  cups 
is  then  applied,  and  allowed  to  remain  in  place  until 
the  entire  cutaneous  area  of  the  affected  locality  is  in 
a  state  of  congestion.  The  skin  being  sufficiently 
livid,  the  cups  are  removed,  and  the  ointment  applied 
and  thoroughly  rubbed  in  with  a  piece  of  chamois 
skin.  This  procedure  should  be  repeated,  if  necessary, 
several  times  each  day.  Narcotic  plasters  may  be  ap- 
plied in  this  manner,  and  allowed  to  remain  in  place 
for  a  considerable  length  of  time,  but,  as  a  rule,  they 
will  be  found  to  be  less  efficacious  than  the  ointments 
frequently  applied. 

The  remedies  best  suited  to  be  applied  in  the  form 
of  salves  in  neuralgic  affections  are  veratrine,  mor- 
phine, belladonna,  aconitia  and  extract  of  opium. 

Aconitia  (one  part  to  thirty)  should  be  rubbed  into 
the  painful  areas  until  numbness  is  induced. 

Veratrine  (one  part  to  twenty-five)  may  be  applied 
twice  or  thrice  daily,  care  being  taken  to  continue  the 
frictions  until  pricking  sensations  are  experienced. 
Erb  recommends  one  part  of  belladonna,  four  parts  of 
glycerine  and  four  parts  of  starch,  the  ointment  to  be 
applied  on  a  compress  or  rubbed  into  the  painful  cuta- 
neous districts. 

"Where  the  paroxysms  of  pain  are  particularly 
violent  and  protracted,  the  employment  of  anaesthetics 
may  be  indicated.  Chloroform  and  ether  may  be  ad- 
ministered in  the  form  of  ointments,  internally  or  by 
means  of  inhalation.  As  a  rule,  the  latter  method  is 
to  be  preferred.     The  inhalations  should  not,  however, 

be  carried  to  such  an  extent  as  to  produce  profound 
9 


130  HEADACHE  AND  NEURALGIA. 

anaesthesia,  but  rather  only  to  a  sufficient  degree  to 
alleviate  the  intense  pains.  When  thus  administered 
they  may  be  continued  for  almost  indefinite  periods, 
provided  there  is  absence  of  cardiac  or  other  organic 
affection. 

The  chief  objection  to  many  general  anaesthetics  is 
the  evanescent  nature  of  their  effects,  which,  when 
the  inhalations  are  discontinued,  soon  pass  off.  It  has 
been  alleged  that  the  paroxysms  are  much  increased  in 
violence  after  the  employment  of  anaesthetics;  but  I 
can  recall  no  instance  of  the  kind  within  my  own  ex- 
perience. 

Hydrate  of  Chloral  administered  in  large  doses  in- 
duces profound  coma,  but  when  given  in  moderate 
quantities  it  rapidily  produces  sleep.  During  the  con- 
tinuance of  its  effects  reflex  action  and  sensation  are 
more  or  less  diminished,  and  death  is  caused  by  par- 
alysis of  the  heart  or  complete  arrest  of  respiration. 
The  effects  of  the  remedy  are  in  great  measure  due  to 
its  action  upon  the  cerebral  protoplasm,  and  not  to 
any  influence  which  it  may  be  supposed  to  exert  upon 
the  intra-cranial  circulation,  I  have  had  occasion  to 
express  my  convictions  upon  this  point  on  many  pre- 
vious occasions,  not  only  with  respect  to  chloral,  but 
also  with  regard  to  all  anaesthetics.  The  action  of 
chloral  upon  the  sensory  apparatus  precedes  its  effects 
upon  the  central  motor  mechanism.  This  is  perhaps 
owing  to  the  greater  facility  with  which  endosmotic 
processes  are  accomplished  among  the  sensory  gan- 
glia. 

The  degree  of  vascularity  of  an  organ  has  also  much 
to  do  with  its  amenability  to  narcotic  influences.  It 
will  be  readily  understood  that  such  must  be  the  case, 
when  it  is  borne  in  mind  that  the  greater  the  volume 
of  blood  circulating  in  an  organ,  the  greater  will  be  the 


NARCOTICS   AND   SEDATIVES.  131 

amount  of  any  narcotic  conveyable  to  that  organ  in  a 
given  length  of  time. 

However  impotent  chloral  may  be  to  allay  pain  in 
very  severe  cases  of  neuralgia,  there  is  no  denying  the 
fact  that  its  administration  in  many  cases  is  followed  by 
excellent  results.  These  good  effects  are  not  attribut- 
able to  any  special  anodyne  influence  of  the  remedy,  but 
rather  to  its  immediate  and  powerful  hypnotic  action. 
How  important  the  element  of  sleep  is  in  severe  cases 
of  neuralgia  cannot  fail  to  be  appreciated  by  those  who 
have  marked  the  rapid  deterioration  that  takes  place 
in  those  suffering  from  the  obstinate  insomnia  induced 
by  severe  and  prolonged  pain.  While  treating  the 
painful  paroxysms  with  every  resource  at  our  com- 
mand, care  should  be  exercised  to  promote  periodic 
sleep,  since  only  thereby  is  it  possible  for  the  patient 
to  counteract  the  devitalizing  influences  of  severe  and 
prolonged  pain. 

Besides  the  remedies  already  discussed,  a  vast  num- 
ber of  other  substances  have  been  recommended  in 
neuralgic  affections  from  time  to  time.  It  would  be  a 
waste  of  time,  however,  to  attempt  to  enumerate  them 
all,  and  I  shall  therefore  content  myself  with  referring 
to  those  of  most  importance. 

Bromide  of  Potassium  is  extremely  valuable  in  those 
cases  characterized  by  unusual  irritability.  It  should 
be  given  during  the  day  in  moderate  doses  (10  grains), 
and  supplemented,  where  there  is  pronounced  insom- 
nia, by  a  small  dose  of  chloral  exhibited  shortly  before 
retiring.  The  tincture  of  hyoscyamus  (in  drachm 
doses)  may  be  substituted  for  the  chloral  with  ad- 
vantage in  some  cases. 


CHAPTER   XXIII. 

OTHER  REMEDIES  WHICH  HAVE  BEEN  RECOMMENDED  IN 
THE  TREATMENT  OF  NEURALGIA. 

Phosphorus  has  been  given  with  good  results  in 
those  cases  of  neuralgia  characterized  by  a  more  or 
less  exhausted  condition  of  the  central  nervous 
system,  or  by  general  or  local  cerebral  anaemia.  The 
dose  may  be  varied  from  one-fiftieth  to  one-twenty- 
fifth  of  a  grain. 

Quinine  has  been  recommended  by  a  number  of  ex- 
cellent authorities,  among  others  by  Erb  and  Trous- 
seau. The  former  has  found  it  of  service  when  com- 
bined with  small  doses  of  morphine  (quinine  three 
grains,  morphia  one- sixth  of  a  grain). 

Arsenic  unquestionably  occupies  a  high  position 
among  anti-neuralgic  remedies.  It  may  be  given  in 
the  form  of  Fowler's  solution  in  doses  of  from  two 
to  eight  drops  three  or  four  times  a  day5  the  amount 
per  diem  being  gradually  increased.  The  hypodermic 
exhibition  of  the  remedy  possesses  certain  advantages, 
and  may  be  resorted  to  in  cases  of  stomachic  trouble 
where  the  introduction  of  remedies  per  or  em  is  contra- 
indicated.  Arsenic  possesses  unusual  efficacy  in  cases 
characterized  by  sanguineous  impoverishment,  as  well 
as  in  those  exhibiting  marked  symptoms  of  cerebral  or 
medullary  exhaustion  or  both. 

Iron  in  its  various  preparations,  and  particularly  the 
chloride  salt,  is  of  no  little  value  in  treatjng  those 
cases  of  neuralgia  in    which  anaemia  and  a  general 


OTHER  REMEDIES  FOR  NEURALGIA.  133 

devitalized  condition  of  the  organism  are  prominent 
features.  There  is  nothing,  however,  of  a  specific 
character  in  the  action  of  any  one  of  the  numerous 
ferruginous  preparations;  only  in  so  far  as  they  affect 
the  nutritive  conditions  of  the  organism  at  large  are 
they  to  be  recommended. 

Strychnia  may  be  given  hypodermically  or  in  com- 
bination with  the  preparations  of  iron.  I  prefer  the 
former  method  of  administration.  What  has  been  said 
with  regard  to  the  various  preparations  of  iron  applies 
in  a  general  sense  to  the  administration  of  strychnia. 
General  anaemia  or  exhaustion  of  the  vital  resources 
of  the  brain  or  spinal  cord  are  the  primary  indications 
for  its  administration. 

Zinc  has  been  extensively  recommended,  and  I  have 
seen  good  results  from  its  employment,  especially  when 
combined  with  the  extract  of  hyoscyamus.  Too  much, 
however,  should  not  be  anticipated  from  the  zinc  prep- 
arations, on  account  of  the  uncertainty  of  the  indica- 
tions for  their  administration. 

Valerian  is  an  excellent  general  sedative  to  the 
nervous  system,  but  is  devoid  of  any  well-marked 
narcotic  effects.  It  has  been  recommended  in  various 
head-pains,  hysteria,  hypochondriasis,  nervous  irrita- 
bility and  likewise  in  the  majority  of  neuralgias.  I 
have  seen  the  best  results  from  its  employment  in 
those  cases  of  neuralgia  in  which  a  strong  hysterical 
element  was  present. 

VERATRIA,    IODINE,    CHLOROFORM,    TURPENTINE,    ETC. 

Embrocations  of  the  above  are  often  effective  in  the 
milder  forms  of  the  affection,  but  usually  fail  to  afford 
relief  in  severe  cases.  On  the  other  hand,  the  cerate 
of  cantharides  often  proves  efficacious    where    other 


134  HEADACHE  AND  NEURALGIA. 

vesicants  have  failed.  There  is  nothing,  however,  of 
a  specifically  tonic  influence  in  this,  as  some  observers 
maintain,  but  the  results  are  doubtless  entirely  attrib- 
utable to  the  derivative  action  of  the  remedy. 

As  we  have  already  had  occasion  to  observe,  the 
electric  brush  and  moxa  often  transcend  in  efficacy  the 
results  obtainable  by  other  derivatives;  and  since  elec- 
tric apparatus  has  become  so  widely  disseminated  these 
methods  of  treatment  may  be  employed  by  those  who 
place  faith  in  derivatives. 

Of  late  years  the  static  electric  current  has  been  re- 
commended in  the  treatment  of  painful  affections,  and 
the  results  obtained  in  some  cases  of  peripheral  neural- 
gia are  occasionally  sufficiently  striking.  Dr.  William 
J.  Morton  has  done  much  towards  investigating  the 
therapeutic  qualities  of  static  electricity,  and  a  perusal 
of  his  writings  upon  this  subject  will  be  found  in- 
structive. 

I  have  already  had  occasion  to  refer  to  a  method  de- 
vised by  myself  for  treating  peripheral  neuralgia  by 
the  application  of  a  certain  degree  of  pressure  to  the 
affected  nerve-stem,  while  at  the  same  time  the  electric 
current  is  passed  through  the  nerve  at  the  point  of 
pressure.  The  good  results  frequently  obtainable  by 
this  mode  of  procedure  are  perhaps  attributable  in  part 
to  the  powerful  counter-stimulation;  and  probably  not 
altogether  to  the  temporary  interruption  of  sensory 
conduction  by  pressure. 

What  is  true  of  the  combination  of  galvanism  with 
pressure  applies  in  a  limited  sense  to  the  application 
of  pressure  alone — a  sufficiently  ancient  expedient,  by 
the  way. 

On  the  whole,  however,  not  much  of  permanent 
good  can  be  expected  from  the  application  of  simple 
pressure  alone;  but  on  the  other  hand,  I  have  seen 


OTHER  REMEDIES   FOR  NEURALGIA.  135 

considerable  and  permanent  benefit  result  from  the 
systematic  and  persistent  employment  of  galvano- 
pressure,  as  described  at  the  beginning  of  this  chapter. 

Baths. — Baths  hot  and  cold  have  long  been  em- 
ployed in  neuralgic  affections.  As  a  rule  hot  baths 
will  be  found  more  serviceable  than  cold;  this  applies 
with  particular  force  to  those  cases  in  which  a  rheu- 
matic element  is  discernible.  On  the  other  hand, 
tepid  and  moderately  cold  baths  are  sometimes  of  use 
in  the  neuralgias  occurring  in  hysterical  and  neurotic 
women.  In  my  own  practice,  I  have  come  to  regard 
the  Turkish  and  Russian  baths  with  special  favor, 
particularly  when  combined  with  subsequent  local  mas- 
sage and  frictions.  Besides  hot  air  and  steam  baths, 
various  mineral  waters  have  been  employed  in  neu- 
ralgic affections  with  more  or  less  success.  Where 
the  general  system  is  greatly  debilitated  ferruginous 
waters  may  be  given,  and  when  combined  with  favor- 
able atmospheric  conditions  and  appropriate  diet  they 
often  prove  valuable. 

Treatment  by  Freezing. — This  is  quite  an  old  expe- 
dient, which  has  lately  been  revived  by  several  physi- 
cians. I  have  not.  however,  been  able  to  discover  that 
these  recent  undertakings  differ  essentially  from  the 
exploits  of  the  older  writers. 

In  common  with  other  neurologists,  I  have  at  times 
had  occasion  to  apply  cold  to  the  spine  and  peripheral 
nerves.  Sometimes  I  have  employed  Chapman's  ice- 
bag,  at  others  I  have  resorted  to  ether  spray.  In 
either  case  it  has  always  seemed  to  me  that  I  was  un- 
able to  produce  in  full  measure  the  benefit  of  the  cold 
applications.  This  applies  with  special  force  to  those 
cases  in  which  I  have  attempted  to  treat  neuralgia  by 
local  freezing.  The  poverty  of  effect  sometimes  wit- 
nessed in  such  cases  I  have  been  led  to  ascribe  to  the 


136 


HEADACHE  AND   NEURALGIA. 


antagonistic  action  of  the  local  blood  stream.  By  the 
antagonistic  action  of  the  blood,  I  mean  the  continual 
raising  of  the  temperature  occasioaed  by  the  uninter- 
rupted accession  of  warm  blood  to  the  part. 

To  overcome  this  difficulty,  I  have  resorted  to  the 
simple  device  shown  in  the  figure.  To  the  end  of  a 
curved  handle,  eight  inches  long,  a  ring,  an  inch  and 
a  half  in  diameter,  is  secured  by  an  appropriate  bifur- 


FlG.   11. 


cation.  This  ring  serves  as  the  frame  of  a  dome  of 
fine  wire  gauze,  with  its  convexity  directed  downward. 
In  employing  the  implement,  the  convex  surface  of 
the  wire  dome  is  pressed  against  that  portion  of  the 
integument  which  it  is  desired  to  refrigerate  (or  anaes- 
thetize). The  instrument  is  held  with  a  full  grasp  of 
the  hand,  and  considerable  pressure  should  be  exerted. 
If  now  a  spray  of  ether,  or,  better,  rhigolene  is  thrown 
upon  the  concave  side  of  the  gauze,  anaesthesia  may  be 


OTHER   REMEDIES   FOR   NEURALGIA.  L37 

in  luced  in  from  a  second  and  a  half  to  three  seconds. 
This  rapid  action  of  the  spray  is  readily  understood,  if 
we  bear  in  mind  that  the  pressure  of  the  gauze  upon 
the  part  effectually  occludes  the  vessels  below  it,  parti- 
cularly the  cutaneous  capillaries.  As  a  consequence, 
there  being  no  warm  blood  stream  to  neutralize  the 
effect  of  the  spray,  its  refrigerating  action  is  given  full 
play,  not  only  on  the  skin,  but  on  the  subjacent  parts 
as  well. 

I  have  used  this  method  of  refrigeration,  in  conjunc- 
tion with  previous  injections  of  weak  solutions  of  co- 
caine (of  one  or  one-half  per  cent.),  in  neuralgia.  Of 
course,  the  method  is  applicable  to  any  part  of  the 
surface,  notably  about  the  head.  For  purposes  of 
local  anaesthesia  or  moderate  refrigeration  it  is  un- 
equalled. When  it  is  employed  for  the  latter  purpose, 
it  is  usually  well  to  resort  to  the  ether  spray,  which 
should  not  be  held  too  near  the  wire  gauze,  if  we  wish 
to  avoid  instantaneous  congelation.  When  it  is  desired 
to  make  painless  punctures  with  the  hypodermic 
needle,  the  device  will  be  found  useful,  as  the  anaes- 
thesia may  be  limited  to  a  circumscribed  spot  of  the 
integument.  It  is  noteworthy  that  insensibility  of  the 
part  may  be  perceptibly  protracted  so  long  as  the  ap- 
pliance is  held  in  place. 

Sometimes  I  have  preceded  the  refrigerating  process 
by  the  injection  in  the  vicinity  of  the  painful  nerve  of 
two  or  three  drops  of  ordinary  distilled  water.  The 
effects  obtainable  from  this  mode  of  operating  seemed 
to  be  quite  equal  to  those  observed  after  the  injection 
of  an  anaesthetic.  It  is  evidently  a  question  in  these 
cases  of  a  more  or  less  permanent  chemical  effect  com- 
bined with  the  mechanical  element  of  freezing. 


CHAPTER  XXIV. 

SURGICAL   EXPEDIENTS. 

It  now  remains  to  note  briefly  certain  operative  pro- 
cedures, which  have  been  resorted  to  by  various  sur- 
geons of  eminence  in  desperate  cases  of  neuralgia, 
where  the  ordinary  methods  of  treatment  have  been 
without  result.  In  this  category  belong  the  operations 
known  as  neurotomy  and  neurectomy.  The  first  pro- 
cedure consists  in  simple  division  of  the  affected 
nerve,  while  in  the  second  mode  of  operating  a  portion 
of  the  affected  nerve  is  resected.  Both  these  opera- 
tions are  undertaken  with  the  view  of  preventing  the 
propagation  of  the  painful  sensations  to  the  brain: 
but,  since  in  neuralgias  of  centric  origin  benefit  is 
sometimes  obtained  by  resort  to  these  operations,  there 
can  be  no  doubt  that  they  exercise  certain  derivative 
influences  in  addition  to  their  more  immediate  physi- 
ological effects  upon  conduction. 

The  observation  that  interference  with  the  circula 
tion  in  a  neuralgic  zone  sometimes  results  in  complete 
and  permanent  removal  of  the  painful  symptoms  has 
induced  surgeons  to  ligate  the  arteries  supplying  such 
districts.  Thus  Trousseau '  has  divided  and  subse- 
quently compressed  the  temporal  and  occipital  arteries 
in  neuralgia  of  the  head;  and  on  several  occasions  the 
results  so  obtained  are  said  to  have  been  excellent. 
Actuated  by  similar  motives  an  eminent  surgeon  of 

1  Cited  by  Erb. 


SURGICAL  EXPEDIENTS.  139 

Germany,1  ligated  the  carotid  artery,  some  years  since 
in  a  desperate  case  of  facial  neuralgia,  with  the  hap- 
piest results,  the  cure  effected  being  complete  and 
permanent.  Such  heroic  surgery  requires  slight  com- 
msntary;  it  is  self-evident  that  dangerous  operations 
of  this  class  should  only  be  undertaken  in  cases  of  the 
most  desperate  character  and  after  all  other  means  of 
treatment  have  been  exhausted. 

1  Nussbaum. 


CHAPTER  XXV. 

SOME  CONCLUDING  OBSERVATIONS  ON  RHEUMATIC,  OSTEAL, 
AND   PERIOSTEAL  HEAD-PAINS. 

Eheumatic  Headache.  —This  is  probably  little  more 
than  a  modification  of  neuralgia,  its  prominent  charac- 
teristics, tenderness  of  the  scalp,  aching  of  the  teeth, 
gums  and  jaws,  and  its  paroxysmal  and  hemi-cranial 
proclivities  leading  unavoidably  to  such  a  conclusion. 

There  is  complete  absence,  as  a  rule,  of  all  disturb- 
ances of  the  cerebral  circulation,  or  other  evidence 
pointing  to  implication  of  the  intra- cranial  structures — 
facts  which  are  directly  opposed  to  the  idea  entertained 
by  some  that  the  dura  or  pia  are  in  some  way  con- 
cerned in  the  production  of  the  morbid  phenomena. 

Treatment. — Unquestionably  the  most  potent  means 
of  combating  this  form  of  head -pain  consists  in  the  ap- 
plication of  heat  to  the  head.  This  is  best  accomplished 
by  means  of  the  water  cap,  (see  Fig.  III.  at  the  be- 
ginning of  this  work),  through  the  coils  of  which 
a  current  of  hot  water  is  allowed  to  circulate.  In  the 
absence  of  this  ingenious  apparatus,  an  india-rubber 
bag  or  even  an  ordinary  wine  bottle  may  be  filled  with 
hot  water  and  applied  over  the  painful  points  with 
good  results.  Should  the  pain  prove  severe  and  obsti 
nate  in  character,  the  injection  of  the  fifth  or  even  the 
eighth  of  a  grain  of  morphine  near  the  seat  of  pain  will 
be  found  to  render  good  service. 

What  has  already  been  said  regarding  the  treatment 
of  neuralgia  in  general,  applies  with  equal  force  to 


CONCLUDING  OBSERVATIONS  ON  HEAD-PAINS.         141 

many  of  these  so-called  cases  of  rheumatic  headache. 
If  the  constitution  exhibits  signs  of  feebleness,  appro- 
priate and  regular  exercise  should  be  prescribed ;  if 
there  are  evidences  of  general  anaemia,  iron,  quinine, 
strychnine,  milk,  eggs,  beef -tea,  rare  beef- steaks  and 
good  claret  wine  are  indicated;  and  if  the  muscles  are 
flabby  and  the  sleep  poor,  the  former  condition  should 
be  met  with  resort  to  daily  massage,  and  the  latter  by 
the  procurement  by  proper  means  of  an  appropriate 
amount  of  brain-rest. 

Osteal  and  Periosteal  Headache. — This  form  of  head- 
ache is  due,  as  we  have  already  had  occasion  to  observe 
in  connection  with  the  subject  of  headache  from  disease, 
to  secondary  syphilis.  This,  at  least,  is  true  of  the 
majority  of  cases.  The  treatment  of  such  cases  is 
largely  a  question  of  the  administration  of  large  doses 
of  the  iodide  of  potassium,  to  which  small  quantities  of 
the  bichloride  of  mercury  may  be  added  or  not  accord- 
ing to  circumstances.  Tonics  and  a  special  dietary 
may  be  prescribed  where  the  general  condition  of  the 
patient  calls  for  such  measures. 


PART   IV. 


SPINAL  IRRITATION. 


CHAPTER  XXVI. 

SPINAL  IRRITATION. 

As  the  affection  known  as  spinal  irritation  represents 
a  complex  of  symptoms  which  reveals  its  close  connec- 
tion with  neuralgic  difficulties;  and  since,  moreover,  it 
is  frequently  found  associated  with  various  painful  con- 
ditions of  the  peripheral  nerves,  it  is  necessary  to  a 
complete  survey  of  our  subject  to  consider  this  distress- 
ing difficulty  somewhat  more  in  detail. 

Let  me  begin,  then,  by  stating  that  spinal  irritation 
occurs  with  great  frequency  both  among  men  and 
women.  The  diagnosis  of  the  affection  sometimes  pre- 
sents difficulties,  on  account  of  its  proneness  to  asso- 
ciate itself  with  other  morbid  conditions,  such  as 
neuralgia,  or  hysteria.  In  typical  cases,  however,  the 
symptoms  observed  are  so  characteristic,  that  they 
must  undoubtedly  be  ascribed  to  a  distinct  pathological 
condition. 

Symptoms. — Like  spinal  exhaustion  the  affection 
develops  gradually  in  the  majority  of  cases.  The  first 
symptoms  to  appear  are  vague  pains  in  the  dorsal 
region  along  the  course  of  the  vertebral  column.  These 
pains  are  usually  provoked  by  slight  fatigue,  such  as 
that  induced  by  walking  or  riding  or  even  driving. 
Sometimes  the  subject  complains  in  the  beginning  of 
dull  burning  sensations  between  the  shoulder  blades 
or  at  the  base  of  the  neck  ;  but  whatever  the  character 
of  the  initiatory  symptoms  may  be,  the  pains  in  the 
back  soon  become  severe,  and  conjointly  with  their 


146  HEADACHE  AND  NEURALGIA, 

evolution  there  is  usually  a  high  degree  of  mental  irri- 
tability. If  at  this  time  an  examination  be  made, 
certain  regions  along  the  course  of  the  vertebral  column 
will  be  found  extremely  sensitive  to  pressure  or  tap- 
ping. A  sponge  saturated  with  hot  water,  passed  along 
the  spine,  evokes  painful  sensations ;  while  the  wire 
brush  employed  in  conjunction  with  the  faradic  bat- 
tery often  discloses  painful  spots,  which  pressure  and 
the  hot  sponge  may,  perchance,  fail  to  reveal.  I  regard 
an  electrical  test  of  the  degree  of  relative  sensitiveness 
as  of  great  practical  importance  in  this  as  well  as  all 
other  forms  of  obscure  spinal  difficulty;  indeed,  by  the 
employment  of  this  test,  I  have  frequently  succeeded 
in  discovering  localized  areas  of  sensitiveness,  which 
else  had  failed  to  reveal  their  presence  altogether. 

I  emphasize  this  point  merely  because  I  believe  that 
far  too  much  importance  has  been  ascribed  to  the  re- 
sults obtainable  by  digital  pressure  and  percussion. 
In  exquisite  cases,  however,  the  morbid  sensitiveness 
is  so  obvious  that  delicate  tests  are  superfluous.  Under 
these  circumstances  the  friction  caused  by  the  clothing 
is  often  intolerable,  while  the  passage  of  the  finger 
along  the  vertebral  column  reveals  hyperaesthesia  of 
the  integument,  which  may  be  of  great  extent  or 
limited  to  spots  no  larger  than  a  small  coin.  Besides 
the  condition  of  hyperaesthesia,  various  paraesthesia, 
such  as  burning  sensations,  formication,  tingling  and 
alternating  feelings  of  hot  and  cold,  are  frequently  met 
with.  On  the  other  hand,  absolute  paralysis  and  an- 
aesthesia are  absent.  Disturbances  of  motility,  when 
they  exist,  merely  consist  in  a  lack  of  capacity  for  the 
performance  of  operations  requiring  endurance  ; — the 
patient  is  soon  weary,  and  even  moderate  use  of  the 
muscles  is  liable  to  provoke  amblitory  pains,  which, 
though  often  intense  in  character,  wander  from,  one 


SPINAL   IRRITATION.  147 

portion  of  the  body  to  another  in  the  most  unaccount- 
able manner.  Sometimes  the  subject  complains  of 
neuralgiform  pains  in  the  face  and  head,  or  in  the 
upper  or  lower  extremities  ;  but  hardly  have  these  sen- 
sations become  established,  when  they  gradually,  and 
in  some  cases  suddenly,  disappear,  only,  however,  to 
reaj>pear  in  the  form  of  vague,  visceral,  genital  or 
vesical  pains.  These  unstable  pains  are  extremely 
characteristic,  and  often  give  rise  to  great  discomfort 
and  apprehension  on  the  part  of  the  patient,  as  well 
as  confusion  in  the  diagnosis. 

Local  spasms  are  a  frequent  concomitant  of  irritable 
spine.  Sometimes  they  assume  the  form  of  fibrillary 
twitchiugs,  located  in  single  muscles,  whereas  in 
another  and  larger  class  of  cases  spasms  are  widely 
distributed,  involving  entire  groups  of  muscles.  There 
is  nothing  of  a  violent  or  epileptoid  character  in  these 
phenomena  ;  they  are  usually  evanescent  and  disap- 
pear under  the  influence  of  appropriate  treatment.  It 
may  readily  be  conceived  that  the  location  of  the 
symptoms  exhibited  in  each  case  will  depend  upon 
whether  the  functional  disturbance  is  found  at  the 
superior,  dorsal,  or  dorso-lumbar  portion  of  the  cord. 

Thus,  if  tenderness  be  found  at  the  cervical  portion 
of  the  cord,  the  subject  is  liable  to  exhibit  vaso-motor 
disturbances  manifesting  themselves  in  sudden  blush- 
ing and  facial  pallor  upon  slight  provocation,  or  in  an 
habitual  frigidity  of  the  extremities.  Again,  if  there 
be  hyperesthesia  above  the  dorsal  segments  of  the 
vertebral  column,  digestive  and  other  disturbances  are 
usually  present ;  while  should  the  lumbar  portions  of 
the  cord  be  functionally  disturbed,  vesical  derange- 
ments, in  the  form  of  an  increased  and  frequent  desire 
to  urinate  give  rise  to  the  erroneous  supposition  that 
there  is  paralysis  of  the  sphincter.     Should  the  func- 


lttS  HEADACHE  AND  NEURALGIA. 

tional  efficiency  of  the  cord  be  more  or  less  affected 
throughout  its  entire  extent,  the  complex  of  symptoms 
is  greatly  amplified — there  are  palpitations,  dyspepsia, 
spermatorrhoea,  vaso-motor  disturbances,  fibrillary 
twitchings,  sleeplessness  and  great  psychical  irrita- 
bility. Spinal  irritation,  though  a  functional  affection, 
is  sometimes  exceedingly  obstinate  in  character;  and 
even  when  we  succeed  in  abating  or  removing  the 
symptoms,  they  are  are  prone  to  return.  Neverthe- 
less, there  is  no  doubt  that,  in  the  vast  majority  of 
cases,  the  disease  is  amenable  to  treatment,  provided 
the  therapeutic  measures  employed  are  appropriate, 
aud  at  the  same  time  rigidly  adhered  to,  even  after 
the  symptoms  have  entirely  disappeared. 

Pathology. — The  pathology  of  spinal  irritation  is  not 
as  satisfactory  as  might  be  desired,  owing  in  part  to 
the  defective  manner  in  which  the  few  autopsies  on 
record  have  been  conducted,  and  in  part  to  the  extreme 
difficulty  of  obtaining  post- mortem  examinations  in 
this,  as  in  other  benignant  nervous  affections.  Some 
writers  entertain  the  belief  that  the  symptoms  are 
wholly  attributable  to  hyperaemia  of  the  cord,  while 
other  observers  are  equally  convinced  that  anaemia  is 
the  true  source  of  the  phenomena.  For  my  own  part  I 
am  entirely  of  the  opinion  that  the  posterior  columns, 
and  more  particularly  those  districts  of  the  same, 
known  as  the  posterior  root  zones,  or  columns  of  Bur- 
dach,  are  involved,  and  I  can  also  conceive  that  the 
posterior  horn  is  implicated;  whether  the  circulatory 
condition  present  is  one  of  hyperaemia  or  anaemia,  I 
am  by  no  means  prepared  to  say  with  certainty.  Of 
this,  however,  I  am  thoroughly  persuaded,  that  the 
nervous  elements  themselves  are  in  a  state  of  abnormal 
irritability,  whatever  the  condition  of  the  circulation 
may  be.    And  I  believe,  moreover,  that  the  question 


SPINAL  IRRITATION.  14:9 

of  primary  importance  in  treatment  is  the  removal  of 
such  irritability  by  appropriate  measures;  and  that 
having  once  accomplished  this,  we  may  confidently 
anticipate  a  corresponding  amelioration  in  the  vascular 
condition,  be  the  same  one  of  anaemia,  hyperemia  or 
alternate  hypersemia  and  anaemia.1  My  views  in  this 
respect  receive  substantial  support  from  the  well- 
known  relationship  of  the  blood-stream  to  all  active 
tissues.  Further  careful  clinical  and  pathological  ob- 
servations may  perhaps  serve  to  increase  our  knowl- 
edge respecting  the  intricate  morphological  questions 
involved. 

Diagnosis. — It  is  undeniable  that  spinal  irritation  is 
an  affection  often  extremely  difficult  of  accurate  diag- 
nosis ;  at  least,  this  is  true  of  the  less  typical  cases. 
Where,  however,  the  symptoms  are  well  marked,  less 
difficulty  will  be  experienced  in  forming  a  correct  con- 
clusion as  to  the  true  nature  of  the  affection. 

The  differentiation  of  spinal  irritation  from  hysteria 
is,  in  a  large  number  of  cases,  exceedingly  difficult. 
This  inability  to  differentiate  the  two  conditions  in 
certain  cases  does  not,  however,  seriously  interfere  with 
the  plan  of  treatment ;  for.  it  is  but  reasonable  to  infer, 
that  where  the  symptoms  of  two  diseases  are  so  inex- 
tricably blended,  there  must  be  a  corresponding  fusion 
of  pathological  causes.  On  the  whole,  therefore,  the 
opinion  that  hysteria  and  spinal  irritation,  though 
separate  affections,  are  frequently  associated  in  one 
and  the  same  individual,  seems  plausible.  Where, 
however,  the  predominant  symptoms  of  hysteria,  gen- 
eral spasms,  globus,  and  paralytic  phenomena  are  found 
in  conjunction  with  only  minor  indications  of  spinal 
irritation,  the  case  should  be  adjudged  one  of  hysteria. 

1  The  possibility  that  we  may  have  to  do  with  these  evanescent 
changes  in  the  circulation  has  already  been  considered  by  various, 
writers, 


150  HEADACHE  AND  NEURALGIA. 

From  spinal  exhaustion,  the  affection  under  consid- 
eration differs  in  this  :  that  in  the  latter  disorder,  dis- 
turbances of  sensibility  predominate,  whereas,  in  the 
former,  marked  diminution  of  the  functional  resources 
of  the  cord  is  the  characteristic  feature. 

Locomotor  ataxia  and  myelitis,  even  in  their  earlier 
stages,  are  not  readily  confounded  with  spinal  irrita- 
tion, since  the  lancinating  pains,  incoordination,  and 
girdling  sensations  peculiar  to  ataxia  are  wanting  : 
and  the  same  may  be  said  of  the  anaesthesia,  paralysis 
of  the  bladder  and  voluntary  muscles  of  the  limbs  and 
contractures,  which  are  so  characteristic  of  the  latter 
affection. 

Spinal  irritation  is  difficult  to  differentiate  from 
hypercemia  of  the  cord,  except  when  the  hyperemia  is 
sufficiently  intense  to  cause  paralysis.  It  has  been 
urged  by  a  medical  writer  of  distinction  that  "  spinal 
irritation  is  made  worse  by  the  administration  of  ergot 
.  .  The  reverse  is  true  of  strychnia,  which,  in  all  cases, 
aggravates  the  symptoms  of  myelitis,  meningitis,  or 
congestion,  while  it  is  an  efficient  means  of  cure  in 
spinal  irritation."  My  own  experience  does  not  accord 
entirely  with  the  above;  indeed,  it  has  led  me,  in  some 
cases,  to  a  diametrically  opposite  conclusion.  At  this 
very  moment,  I  have  under  my  care  a  gentleman  mani- 
festing all  the  appearances  of  spinal  irritation,  in  whom 
the  symptoms  of  the  affection  are  greatly  aggravated 
by  strychnia  in  doses  of  one  forty-eighth  of  a  grain. 
This  phenomena  is  readily  explained  if  we  admit  that 
the  sensory  districts  of  the  cord  are  in  a  state  of  ereth- 
ism. It  is  a  matter  of  secondary  importance  whether 
this  condition  of  irritability  is  accompanied  by  a  hyper- 
aemic  or  anaemic  state  of  the  cord  or  not. 

1  "A  Treatise  on  the  Diseases  of  the  Nervous  System.1'  By  Wil- 
liam A.  Hammond.    Page  47,  seventh  edition,  1881. 


SPINAL  IRRITATION.  151 

Meningeal  tumors,  during  their  early  stages,  may 
doubtless  give  rise  to  symptoms  closely  resembling 
those  induced  by  spinal  irritation.  But  the  disturb- 
ances produced  by  tumors  are  stable  in  character,  and 
confine  themselves  with  more  or  less  strictness  to  cer- 
tain districts,  whereas,  the  migratory  character  of  the 
symptoms  of  spinal  irritation  constitutes  a  distinctive 
feature, 

On  the  whole,  therefore,  where  severe  pain  of  an 
atnblitory  character  exists  in  the  spine,  accompanied 
by  great  tenderness  of  the  spinous  processes,  but  with- 
out paralysis,  anaesthesia,  or  other  severe  symptom 
pointing  to  grave  organic  trouble,  it  is  safe  to  assume 
that  we  have  to  do  with  a  case  of  spinal  irritation. 

Treatment. — In  the  treatment  of  spinal  irritation, 
the  attention  of  the  physician  should  be  directed  to 
those  symptoms  which  owe  their  origin  to  the  func- 
tional derangement  of  the  cord,  on  the  one  hand,  and 
to  those  manifestly  attributable  to  a  secondary  condi- 
tion of  cerebral  erethism  on  the  other. 

The  removal  of  the  local  hyperaesthetic  spots,  though 
often  a  protracted  operation,  is  usually  attainable  by 
the  employment  of  a  sufficient  amount  of  patience,  con- 
joined with  appropriate  local  measures.  Among  these 
have  been  recommended  counter  irritation  by  means 
of  blisters,  or  the  actual  cautery.  I  cannot  say  I  resort 
to  these  measures  as  much  as  formerly,  for  reasons 
which  I  will  presently  state.  On  the  other  hand,  the 
application  of  the  galvanic  current  to  the  spine,  one 
electrode  being  placed  two  or  three  inches  above  the 
painful  point,  and  the  other  an  equal  distance  below 
it,  will  be  found  of  service  in  many  instances.  The  ap- 
plications should  last  from  fifteen  minutes  to  half  an 
hour,  and  should  be  undertaken  at  least  once  a  day. 
General  faradization  also  yields  excellent  results,  espec- 


152  HEADACHE  AND  NEURALGIA. 

ially  in  cases  of  debility  and  anaemia.  Of  internal  rem- 
edies, iron,  qninine,  and  zinc  will  be  found  most  useful, 
where  the  condition  of  the  stomach  will  permit  the 
employment  of  medicine. 

Neuralgic  pains,  stomachic  difficulties,  and  other 
complications  should  be  treated  symptomatically  in 
the  order  of  their  occurrence.  We  have  already  al- 
luded to  the  secondary  condition  of  cerebral  erethism, 
manifesting  itself  in  insomnia  and  extreme  mental  irri- 
tability. These  latter  symptoms  exert  an  exceedingly 
prejudicial  influence  upoa  the  general  health  of  the 
patient,  and  serve  to  sensibly  diminish  the  prospects 
of  a  speedy  recovery  ;  and  they  should,  therefore,  claim 
the  particular  attention  of  the  attending  physician. 
For  an  extended  account  of  the  measures  to  be 
adopted  in  the  treatment  of  the  various  derange- 
ments of  sleep,  I  would  refer  to  the  special  chapter 
upon  that  subject  at  the  end  of  this  work,  and  also 
to  my  former  publications.1  As  regards  the  irrita- 
bility, we  would  recommend  the  employment  of  the 
bromides,  Mariani's  coca  wine,  and,  where  there  is  no 
tendency  to  vaso-motor  derangements  (cerebral  hyper- 
emia), stimulants  may  be  administered  in  moderate 
quantities.  And  here,  I  would  enter  a  protest  against 
the  extravagant  and  hysterical  utterances  of  certain 
persons  regarding  what  they  conceive  as  dangerous 
attributes  of  the  coca-preparations.  In  this  matter,  I 
agree  with  Hammond,  that  there  is  no  foundation, 
whatever,  for  such  apprehensiveness.  I  usually  give 
brandy,  whiskey,  or  rum  ;  or,  where  the  stomach  will 
bear  it,  Burgundy  or  Bordeaux,  wThich  may  be  taken 
at  dinner.     The  administration  of  stimulants  is,  how- 

1  ' '  Brain  Rest,  being  a  Disquisition  on  the  Curative  Properties 
of  Prolonged  Sleep."  By  J.  Leonard  Corning,  M.  D.  New  York: 
(j.  P.  Putnam's  Sons,  1885,     Second  edition,  page  36,  et  seg. 


SPINAL  IRRITATION.  L53 

ever,  often  impossible,  owing  to  extreme  suscepti- 
bility. 

After  treating  several  cases,  the  physician  inevitably 
becomes  aware  of  the  fact  that  in  a  certain  proportion, 
his  efforts  do  not  meet  with  complete  success;  there  is, 
in  a  word,  an  inordinate  persistence  of  soreness  and 
pain  on  pressure  above  the  vertebrae — a  condition  dis- 
couraging at  once  to  physician  and  patient.  In  such 
cases,  I  have  frequently  resorted  to  local  medication  of 
the  cord  by  means  of  deep  injections  between  the  ver- 
tebrae of  the  hydrochlorate  of  cocaine,  in  solutions  of 
varying  strength.  The  hyperaesthetic  spots  are  those 
which  I  usually  select  for  the  injections,  but  I  have 
no  hesitancy  in  making  from  six  to  one  dozen  or  more 
such  injections  along  the  course  of  the  spine.  Care 
should  be  exercised,  in  making  these  injections,  to 
place  the  needle  as  near  the  ligamentum  insterspino- 
sum  as  possible.1 

The  results  obtained  by  this  plan  of  treatment  are 
often  astonishingly  favorable;  and  it  is  a  matter  of 
surprise  to  me  that  in  the  face  of  the  excellent  effects 
obtained  by  local  medication  of  nerves,  literature  con- 
tained nothing  concerning  the  application  of  this  prin- 
ciple previous  to  publication  of  my  first  paper.2  I  will 
merely  add  that  in  the  New  York  Medical  Journal  for 
November  6,  1886,  I  have  described  a  painless  method 
of  anaesthetizing  the  skin  which  I  believe  is  destined 
to  prove  an  important  aid  in  the  treatment  of  hyper- 
aesthetic  conditions  of  the  nervous  system. 

As  the  method  of  local  medication  here  referred  to 

1  For  the  benefit  of  those  who  are  interested  in  the  development 
of  more  potent  methods  of  affecting  the  cord  in  disease,  I  would 
refer  to  my  article  contained  in  the  "  New  York  Medical  Journal" 
for  October  31,  1885,  and  also  to  my  monograph  on  "  Local  Anaes- 
thesia."   New  York;  D.  Appleton&  Co., 

8  Op.  cit. 


154  HEADACHE  AND  NEURALGIA. 

is  destined,  in  my  judgment,  to  render  good  service 
in  these  obstinate  painful  conditions  of  the  cord,  I  pro- 
pose to  discuss  the  procedure  at  length,  more  particu- 
larly with  a  view  to  elucidating  the  technical  points 
involved.  I  desire,  also,  to  show  by  what  simple  means 
it  is  possible  to  deposit  the  medicinal  substance  in  large 
quantity,  in  the  immediate  vicinity  of  the  spinal  cord, 
and  yet  avoid  the  slightest  danger  of  wounding  the 
latter. 

Some  time  ago,  in  an  article  published  in  the  New 
York  Medical  Journal  for  October  31,  1885,  I  showed 
that  when  a  given  amount  of  a  medicament  is  injected 
into  the  vicinity  of  the  spinal  cord  certain  modifications 
in  the  functions  of  the  latter  may  be  induced.1 

Thus,  when  strychnine  is  injected  in  this  manner, 
the  functions  of  the  cord,  and  notably  the  reflexes, 
are  greatly  exalted;  much  more  so,  in  fact,  than  if  the 
medicament  had  been  simply  injected  into  the  general 
circulation,  as  in  ordinary  hypodermic  medication. 
Ou  the  other  hand,  the  modifications  in  function  which 
I  observed  after  injection  of  an  anaesthetic,  such  as  co- 
caine, were  sensory  in  character — such,  for  example,  as 
more  or  less  complete  anaesthesias,  tingling,  numbness, 
and  various  other  paraesthesiae.  these  phenomena  being 
principally  confined  to  the  parts  below  the  point  of  in- 
jection. The  line  of  argument  which  led  up  to  these 
results  it  is  not  necessary  for  me  to  detail  on  this 
occasion;  enough,  that  the  experiments,  which  were  at 
first  conducted  on  dogs,  were  afterward  verified  in  man 
and  the  expedient  has  since  been  resorted  to  on  several 
occasions.  I  was  careful,  too,  to  point  out  that  this 
principle  of  medication  offered  an  admirable  and  here- 
tofore unsuspected  and  potent  means  of  treating  cer- 

JRead  before  the  Medical  Society  of  the  State  of  New  York, 
February  7,  1888. 


SPINAL  IRRITATION.  155 

taiD  derangements  of  the  spinal  cord.  Thus,  it  was 
shown  that  the  painful  phenomena  which  are  present 
in  spinal  irritation  may  be  combated  by  resort  to  this 
exceedingly  direct  and  effective  therapeutic  procedure  ; 
and  to  this  I  may  add  that  the  permanency  of  the 
effects  produced  are  enhanced  by  the  combination  of 
cocaine  with  other  remedies. 

Having  ascertained  this  much,  it  occurred  to  me 
that  it  would  be  a  matter  of  practical  interest  to  pursue 
these  researches  further  ;  accordingly,  shortly  after 
the  publication  of  the  paper  above  referred  to,  I  con- 
ducted the  following  experiments  :2 

1.  I  injected  a  solution  of  sulphate  of  strychnine 
under  the  skin  of  a  rabbit  in  sufficient  quantity  to 
induce  general  convulsions.  I  then  injected  a  quarter 
of  a  grain  of  hydrochlorate  of  cocaine  subcutaneously, 
but  without  modifying  in  the  slightest  degree  the  con- 
vulsive phenomena;  in  a  word,  I  may  state  that  I  con- 
tinued to  inject  this  drug  (hydrochlorate  of  cocaine) 
until  well-marked  toxic  symptoms  had  been  developed, 
but  was  not  successful  in  modifying  the  convulsions 
to  the  slightest  extent.  The  results  thus  obtained  are 
directly  at  variance  with  those  recorded  by  certain 
recent  German  observers. 

2.  In  this  experiment  I  again  induced  the  convul- 
sions by  subcutaneous  injections  of  the  sulphate  of 
strychnine,  but  instead  of  injecting  the  cocaine  under 
the  skin  of  the  animal,  I  injected  ten  minims  of  the 
four-per-  cent,  solution  behveen  the  spinous  processes  of 
the  vertebrae.  The  first  injection  was  not  followed 
by  any  marked  reduction  in  the  tetanic  symptoms  for 
several  minutes  ;  therefore,  at  the  end  of  ten  minutes 

1  See  in  "The  Medical  Record"  for  March  17th,  1888,  an  article 
entitled  :  "A  Further  Contribution  on  Local  Medication  of  the 
Spinal  Cord,  with  Cases,"  by  J.  Leonard  Corning,  M.D. 


156  HEADACHE  AND  NEURALGIA. 

I  injected  the  same  quantity  as  before,  except  that  it 
was  distributed  in  several  inter-vertebral  spaces.  After 
the  lapse  of  about  fifteen  minutes  from  the  first  injec- 
tion the  severity  of  the  convulsions  had  markedly 
decreased,  and  the  animal  could  be  handled  without 
their  induction. 

From  the  first  experiment,  therefore,  it  is  clear  that 
the  injection  of  cocaine  preparations  into  the  general 
circulation,  even  in  large  quantities,  is  not  sufficient 
to  counteract  the  toxic  effects  of  strychnine.  Experi- 
ment shows,  on  the  other  hand,  that  when  the  drug  is 
brought  in  a  concentrated  form  into  the  immediate 
vicinity  of  the  cord  the  reflex  phenomena  may  be 
markedly  diminished,  provided,  of  course,  that  a  too 
large  quantity  of  strychnine  has  not  been  taken. 
When  we  consider  how  much  greater  the  local  than 
the  general  action  of  the  drug  is,  this  disparity  of  effect 
is  easily  accounted  for.  But  it  is  in  the  painful  affec- 
tions of  the  cord,  such  as  ataxia,  that  I  believe  we  shall 
attain  notable  results  by  resorting  to  this  direct  method 
of  medication.  So  convinced  have  I  become  of  the 
necessity  of  making  some  radical  departure  in  our 
mode  of  attacking  these  painful  maladies,  that  when 
I  had  observed  the  phenomena  recorded  in  my  first 
paper,1  I  resolved,  as  soon  as  an  opportunity  should 
present,  to  test  this  local  medication  in  the  painful 
affections  of  the  cord.  There  was  one  obstacle  to  the 
execution  of  these  plans,  however,  which  puzzled  me 
for  a  long  time.  Briefly  stated,  the  problem  in  ques- 
tion is  this:  How  is  the  physician  to  know  how  far 
he  may  thrust  the  hollow  needle,  used  in  transmitting 
the  medicament  from  the  syringe  to  the  vicinity  of 
the  cord,  without  danger  of  wounding  the  latter  ? 

1  "Spinal  Anaesthesia  and  Local  Medication  of  the  Cord,"  the 
"New  York  Medical  Journal,"  October  31,1885;  see  also  "Local 
Anaesthesia,"  D.  Appleton  &  Co. 


Spinal  irritation.  157 

As  I  have  said,  this  problem  puzzled  me  for  a  long 
time  ;  and  yet  there  was  no  evading  it,  for  I  saw  at 
once  that  if  the  procedure  were  to  prove  effective  it 
could  only  be  by  depositing  the  medicinal  substance  as 
close  to  the  cord  as  possible.  There  are  not  many  prob- 
lems in  this  life,  however,  which  cannot  be  solved  by 
hard  and  properly  directed  thinking,  and  this  one 
proved  no  exception  to  the  rule.  To  make  a  long  story 
short,  I  succeeded  completely  ;  and  this  is  how  the 
matter  was  accomplished.  Having  examined  the  ver- 
tebrae of  the  lower  portion  of  the  spinal  column,  I  ob- 
served that  the  posterior  surface  of  the  transverse 
process,  even  at  its  greatest  depression,  though  almost 
on  a  level  with  the  posterior  aspect  of  the  foramen 
vertebrae,  did  not  fall  at  all,  or,  in  rare  cases,  possibly 
very  slightly  below  it.  This  is  especially  true  of  the 
ninth,  tenth,  eleventh,  and  twelfth  dorsal,  and  of  the 
first  and  second  lumbar  vertebrae.  As  soon  as  I  had 
observed  this  anatomical  coincidence,  I  saw  at  once 
that,  in  so  far  as  the  lower  vertebrae  were  concerned, 
the  problem  of  approaching  the  immediate  vicinity  of 
the  cord  with  the  point  of  a  hypodermic  needle,  without 
danger  of  wounding  it,  was  solved.  In  a  word,  to  make 
the  matter  short,  the  simple  technique  which  I  elabor- 
ated on  the  basis  of  these  observations  is  as  follows  : 

1.  I  first,  as  a  rule,  induce  a  condition  of  cutaneous 
anaesthesia  in  the  vicinity  of  the  spinous  processes  of 
the  tenth  and  eleventh  dorsal  vertebrae  almost  as  large 
as  a  silver  dollar.  This  I  do  simply  for  the  comfort  of 
the  patient  and  for  no  other  purpose  The  electro- 
chemical method  '  elaborated  by  me,  or  the  hypodermic 
syringe,  may  be  employed  for  the  purpose. 

2.  I  now  call  into  requisition  a  fine  needle,  about 
three  inches  long,  provided  with  a  handle  and  a  sliding 

1  See  the  "  New  York  Medical  Journal "  for  November  6,  1886. 


158 


HEADACHE   AND   NEUKALGIA. 


nut  (Fig.  XII).  The  latter  may  be  fixed  at  any  portion 
of  the  continuity  of  the  needle  by  means  of  the  screw. 
This  needle  I  thrust  down  (about  half  an  inch  laterally 


Fig.  12.— Exploratory  Needle. 


from  the  spinous  process  of  the  tenth  dorsal  vertebrae) 
until  the  bone  is  reached.  The  nut  is  then  pushed 
down  till  it  rests  lightly  upon  the  skin,  (Fig.  XIII)  and 


Fig.  13. — Showing  Manner  of  Employing  the  Exploratory  Needle. 

is  secured  in  place  by  means  of  the  screw.      I  then 
withdraw  the  needle. 
It  is  now  clear,  from  what  has  already  been  said, 


SPINAL   IRRITATION. 


159 


that  the  distance  from  the  nut  to  the  point  of  the 
needle  corresponds  almost  exactly  with  the  distance 
from  the  surface  of  the  integument  to  the  cord.  To 
make  assurance  doubly  sure,  however,  I  am  in  the 
habit  of  subtracting  two  or  three  millimetres  from  the 
measurement  thus  attained 


Fig.  14. — Hollow  Needle  and  Sliding  Nut. 

3.  Upon  a  fine  cannula  (Fig.  XIV),  likewise  provided 
with  a  sliding  nut,  the  distance  previously  noted  upon 
the  needle  is  measured  off  (minus,  two  or  three  milli- 
metres), and  the  nut  secured  firmly  in  place. 

4.  This  hollow  needle  is  then  attached  to  a  syringe 
(Pig. XV)  of  one  hundred  minims  capacity,  filled  with  a 


Fig.  15.— Syringe  op  One  Hundred  Minims  Capacity. 

one-and-a-half -per-cent.  solution  of  the  hydrochlorate 
of  cocaine,  to  which  is  added  about  gr.  TV  of  pyrogal- 
lic  acid.  I  have  used  solutions  of  various  strengths, 
but  am  inclined  to  give  preference  to  those  of  one-and- 
a-half  per  cent. 

5.  The  cannula  is  now  thrust  into  the  tissue  between 
the  spinous  processes  of  the  tenth  and  eleventh  dorsal 
vertebras  (I  have  sometimes  inserted  it  between  the 


160  HEADACHE  AND  NEURALGIA. 

ninth  and  tenth),  until  the  nut,  previously  firmly  fixed 
as  described,  rests  upon  the  integument.1  The  con- 
tents of  the  syringe  are  now  slowly  emptied,  and  the 
needle  withdrawn. 

6.  The  patient  should  now  be  allowed  to  lie  on  his 
abdomen,  with  his  legs  hanging  over  the  edge  of  the 
sofa  or  bed  in  such  wise  as  to  put  the  dorsal  muscles 
on  the  stretch.  This  manoeuvre  presses  the  fluid  in 
the  direction  of  the  least  resistance,  i.e.  the  cord,  be 
sides  causing  the  rigid  muscles  to  act,  in  a  certain  sense, 
as  an  incarcerating  mechanism;  that  is  to  say,  that,  in 
their  rigid  condition,  they  prevent  the  medicament,  to 
some  extent,  from  being  absorbed  by  the  tissues  out- 
side of  the  spinal  canal.  Of  course,  when  the  solution 
has  once  entered  the  spinal  canal,  we  can  do  nothing 
to  keep  it  in  permanent  contact  with  the  cord.  The 
circulation  at  the  lower  segments  of  the  cord  is,  how- 
ever, as  is  well  known,  extremely  lethargic,  so  that 
the  solution  cannot  be  washed  away  very  rapidly. 
This  torpid  state  of  the  circulation,  already  alluded  to 
by  Brown-Sequard  in  his  papers  on  paraplegia,  no 
doubt  accounts  for  the  persistence  of  numbness  and 
anaesthesia  more  or  less  profound  after  the  injections 
have  been  made. 

So  much,  then,  for  the  technique  of  this  mode  of 
treatment.  ^Relatively  long  as  is  necessarily  the  de- 
scription, the  execution  of  the  manipulations  them- 
selves is  by  no  means  so  difficult  as  might  be  imagined. 
I  have  employed  the  procedure  many  times,  sometimes 
using  cocaine  alone,  and  sometimes  combined  with  the 
tincture  of  aconite  or  pyrogallic  acid,  according  to  the 
effects  which  it  is  desired  to  obtain. 

1  When  the  injections  are  made  in  the  upper  and  middle  dorsal 
regions  the  precautions  detailed  above  are  not  so  necessary, 
though,  perhaps,  on  the  whole,  they  are  preferable. 


SPINAL  IRRITATION.  161 

In  the  affection  commonly  known  as  spinal  irritation, 
whether  there  be  a  condition  of  congestion  or  anaemia 
I  care  not,  its  effects  are  certainly  in  the  highest  degree 
beneficial,  as  I  have  already  had  occasion  to  demon- 
strate to  my  entire  satisfaction  in  several  cases.  How 
much  may  be  obtained  in  inflammatory  affections  of 
the  cord  only  an  extended  experience  can,  of  course, 
determine.  In  purely  functional  derangements,  how- 
ever, its  efficacy  is  beyond  question. 

The  following  brief  synopsis  of  cases  will  serve  to 
exhibit  the  promptness  and  permanency  of  the  effects 
often  obtainable  by  resort  to  this  mode  of  treatment. 

1.  Mrs.  C ,  a  young  married  lady,  consulted  me 

some  months  since  on  account  of  severe  pains  between 
the  shoulders  and  at  the  back  of  the  neck.  These 
pains  were  exceedingly  persistent.  They  were  readily 
evoked  by  slight  exertion,  such  as  bending  forward, 
walking,  or  lifting  small  objects,  and  they  had  failed 
to  yield  to  any  sort  of  treatment  whatsoever.  Previous 
to  consulting  me,  this  good  lady  had  submitted  to  an 
ordeal  in  the  way  of  treatment  which  was  as  unique 
as  it  was  ineffectual.  Her  back  had  been  cauterized 
repeatedly ;  she  had  been  plied  with  all  manner  of 
drugs,  so  that  her  stomach  was  in  an  exceedingly  bad 
condition  ;  and  last,  but  not  least,  her  vagina  had  been 
bedouched,  besalved,  and  bestuffed,  according  to  the 
most  exacting  tenets  of  modern  uteromania.  It  was 
natural,  in  the  face  of  all  this,  that  the  mind  of  the 
patient  should  have  become  somewhat  hypochondria- 
cal ;  and  it  was  equally  to  be  anticipated  that  her 
morbid  reflections  would  centre  upon  the  pelvic  organs  ; 
so  that  when,  during  the  consultation,  she  asked  me, 
with  considerable  trepidation,  whether  I  did  not  believe 
that  she  "  had  better  have  her  womb  cut  out  to  cure  the 
pain  in  her  back,"  I  was  not  inordinately  astonished. 
6 


162  HEADACHE  AND  NEURALGIA. 

All  examination  of  the  spine  revealed  three  exceed- 
ingly tender  points  at  the  upper  and  middle  dorsal  re- 
gion. At  two  of  these  points  pain  was  at  once  induced 
by  pressure,  at  the  third  spot  it  could  only  be  evoked 
by  the  application  of  the  electric  brush. 

Such  being  about  the  condition  of  affairs,  I  decided, 
with  the  patient's  full  concurrence,  to  try  the  effect 
of  local  medication  at  the  seat  of  pain. 

Having  filled  the  large  glass  syringe  already  referred 
to  with  a  solution  containing  gr.  -fc  of  pyrogallic  acid 
and  one-and-a-half  grain  of  cocaine  to  one  hundred 
minims  of  water,  I  injected  the  entire  contents  of  the 
syringe  (one  hundred  minims)  into  the  upper  painful 
spot.  Ten  minutes  later  there  was  no  pain  at  the 
point  of  injection  ;  and  what,  at  the  time,  seemed  still 
more  remarkable  to  me,  the  tenderness  had  entirety 
disappeared  from  the  painful  spots  below  the  point  of 
injection.  As  I  now  look  at  it,  I  am  inclined  to  ascribe 
this  striking  phenomenon  to  the  gradual  deportation  of 
the  anaesthetic  into  the  regions  below  the  point  of  in- 
troduction. This  explanation  would  seem  to  accord 
well  with  what  we  know  of  the  distribution  of  the 
blood-vessels  in  the  spinal  canal ;  but  I  will  not  incur 
the  danger  of  wearying  the  reader  by  further  specu- 
lations on  this  point. 

Enough  that  after  this  single  injection  the  patient 
was  able  to  execute  all  kinds  of  movements,  such  as 
bending  forward,  lifting  objects  from  the  floor,  and 
the  like,  without  the  slightest  pain.  This  exemption 
from  suffering  continued  during  the  eleven  following 
days,  when  having,  as  she  thought,  exposed  herself  to 
the  effects  of  cold  while  riding  in  a  horse-car,  there 
was  a  return  of  severe  pain.  I  again  made  an  injection 
as  before,  selecting  for  the  purpose  the  region  about 
the  second  painful  spot.     A  like  happy  issue  was  the 


SPINAL  IRRITATION.  163 

result,  complete  abolition  of  pain,  an  exemption  which 
has  continued,  so  far  as  I  know,  up  to  date. 

2.  Neurotic  youth  of  sixteen.  Has  been  addicted  to 
masturbation  for  some  years,  a  habit  which  he  says 
he  acquired  at  school.  His  parents,  however,  insist 
that  he  was  addicted  to  the  practice  before  going  to 
school.  That  as  it  may  be,  there  is  pretty  good  evi- 
dence that  he  has  masturbated  more  or  less  since  his 
tenth  year. 

Six  months  ago  I  was  consulted  by  the  parents  of 
the  boy  on  account  of  a  severe  pain  located  at  the 
lower  portion  of  the  back.  On  examination  tender- 
ness on  pressure  was  found  at  the  eighth  dorsal  and 
tenth  lumbar  vertebrae.  When  the  patient  attempted 
to  bend  forward  the  pain  evoked  was  quite  acute.  Of 
late  he  has  been  able  to  indulge  in  walking  but  little, 
owing  to  the  painful  sensations  to  which  it,  as  well  as 
all  forms  of  exercise,  gives  rise.  Is  sleepless,  irritable, 
and  depressed. 

Most  of  the  conventional  remedies  having  been  tried 
without  avail  in  his  case,  I  determined,  his  parents 
readily  consenting,  to  try  the  efficacy  of  local  medica- 
tion. Accordingly,  I  injected  seventy-five  minims  of 
an  aqueous  solution  containing  gr.  TV  of  pyrogallic 
acid,  and  gr.  1J  of  cocaine  at  each  point  of  tenderness. 

In  ten  minutes  the  patient  could  execute  all  kinds 
of  bodily  contortions,  such  as  bending  forward,  later- 
ally, and  even  backward. 

The  relief  lasted  for  hours,  and,  indeed,  for  the  next 
four  days  there  was  marked*  improvement.  At  the 
end  of  that  time,  however,  the  local  tenderness  again 
appearing,  if  anything,  in  a  more  aggravated  form 
than  at  first,  I  again  made  the  injections  precisely  as 
before,  and  with  the  same  results,  except  that  the 
effects  were  altogether  more  permanent,  lasting  for 


164:  HEADACHE   AND  NEURALGIA. 

the  following  three  or  four  weeks.  A  slight  degree  of 
tenderness  then  made  its  appearance,  and,  strange  to 
relate,  at  a  point  higher  up.  An  injection  was  at  once 
made  at  the  painful  point,  resulting,  as  usual,  in  com- 
plete abolition  of  all  tenderness.  Several  months  hav- 
ing now  elapsed  and  no  complaint  having  been  made, 
except  on  account  of  occasional  cutaneous  hyperaes- 
thesia,  which  is  as  usual  relieved  by  a  strip  of  ordinary 
belladonna  plaster,  I  think  that  we  are  perhaps  justi- 
fied in  looking  upon  the  case  as  practically  cured. 

3.  A  young  man,  twenty -two  years  of  age,  was  re- 
ferred to  me  some  time  since  by  Dr.  L.  Bolton  Bangs. 
Briefly,  the  patient  had  been  operated  upon  for  stric- 
ture by  Dr.  Bangs,  and  six  days  afterward  developed 
severe  spinal  irritation. 

More  or  less  dull  pain  was  felt  in  the  lumbar  region 
and  sacrum,  extending  to  the  lower  dorsal  vertebrae. 
At  the  seventh  dorsal  vertebra  pain  on  pressure  was 
exceedingly  acute  ;  and  from  this  point  intercostal 
pains  of  great  intensity,  particularly  on  the  left  side, 
were  radiated,  so  that  breathing  was  shallow  and  ac- 
companied by  much  distress. 

Dr.  Bangs  had  recourse  to  large  doses  of  ergot,  and 
applied  the  actual  cautery  to  the  back  of  the  patient 
in  a  most  thorough  manner.  Still,  though  there  was 
apparently  some  amelioration,  it  was  felt  that  the  relief 
experienced  was  far  from  satisfactory. 

Accordingly,  Dr.  Bangs,  being  cognizant  of  my  in- 
terest in  local  medication  of  the  cord,  requested  me  to  as- 
certain whether  the  severe  pains,  and  particularly  those 
about  the  chest,  could  not  be  relieved  by  local  means. 

Appreciating  the  necessity  of  affording  as  speedy 
relief  as  possible,  I  at  once  injected  one  hundred  min- 
ims of  an  aqueous  solution  containing  about  one-six- 
tieth of  a  grain  of  pyrogallic  acid,  and  one  grain  of 


SPINAL  IRRITATION.  165 

cocaine,  into  the  painful  zone  in  the  immediate  vicinity 
of  the  seventh  dorsal  vertebra. 

Ten  minutes  after  the  injection  had  been  made,  the 
patient  experienced  complete  relief  from  the  intercostal 
pains.  He  could  bend  the  body  from  right  to  left, 
backward  and  forward,  and  inflate  his  lungs  to  their 
fullest  capacity  without  the  semblance  of  pain.  Pres- 
sure upon  the  seventh  dorsal  vertebra  also  failed  to 
evoke  the  slightest  sensation  of  discomfort.  During 
the  following  two  hours  patient  remained  in  my  office, 
and  at  the  end  of  that  time,  there  being  no  sign  of  re- 
turning discomfort,  I  allowed  him  to  walk  home  un- 
attended. Three  days  later  he  again  reported  at  my 
office,  and,  though  an  examination  of  his  spine  re- 
vealed some  superficial  soreness,  the  deep-seated  pains 
were  not  evoked,  nor  had  there  been  any  return  of  the 
intercostal  pains.  For  the  relief  of  the  cutaneous 
soreness  the  simple  application  of  a  strip  of  belladonna 
plaster  was  found  sufficient. 

The  subsequent  course  of  the  case  presents  some 
interesting  genito-urinary  features,  which  I  trust  at 
some  future  date  Dr.  Bangs  will  elucidate  with  his  ac- 
customed skill.  As  for  the  spinal  irritation,  I  feel  that 
a  cure  has  been  practically  effected,  although  the  severe 
changes  in  temperature  experienced  during  the  last 
few  weeks  have  evoked  at  times  a  slight  return  of 
soreness.  This  soreness  has  been  easily  controlled  by 
moderate  doses  of  antipyrine. 

Several  weeks  after  the  above  was  published,  patient 
called  upon  me  and  informed  me  that  he  had  long 
since  discontinued  the  antipyren,  as  the  pain  had 
entirely  left  him. 

4.  Old  case  of  spinal  concussion  in  a  gentleman  of 
fifty,  who  met  with  a  railway  accident  some  years 
ago.    Has  been  under  my  care  for  many  months,  and, 


166  HEADACHE  AND  NEURALGIA. 

although  able  to  dispel  the  psychical  depression  from 
which  he  has  long  been  a  sufferer,  I  was,  until  re- 
cently, unable  to  abate  a  severe  soreness  at  the  region 
of  the  lower  dorsal  vertebrae.  This  soreness  he  as- 
cribes to  the  fact  that  he  was  caught  between  two 
seats  of  the  car  on  the  occasion  of  the  railway  accident 
above  referred  to. 

Having  tried  all  the  usual  superficial  local  measures 
without  success,  I  undertook,  with  the  patient's  con- 
sent, to  abate  the  symptoms  by  resort  to  deep  local 
medication.  As  in  the  previous  cases,  the  injections 
were  conducted  at  the  seat  of  pain,  with  every  precau- 
tion, and  with  the  result  of  affording  complete  and  im- 
mediate relief  from  the  painful  symptoms.  Four  days 
after  the  injections  there  was  some  slight  return  of 
soreness,  but  this  was  at  once  controlled  by  supple- 
mentary injections.  Some  weeks  have  now  elapsed 
since  the  last  injection  was  made  and  there  has  been 
no  return  of  pain. 

5.  N.  I.,  a  young  lady  of  twenty- three  years  of  age, 
was  brought  to  me  in  consultation  by  Dr.  Simpson,  a 
prominent  practitioner  of  Massachusetts. 

The  following  notes  of  her  case  are  compiled  in  part 
from  Dr.  Simpson's  letters  and  in  part  from  my  own 
case  book.  Her  general  health  is  good,  appetite  fair. 
She  is  well  nourished,  but  has  suffered,  for  the  past 
five  years,  from  severe  pain  in  the  head  and  back.  On 
examining  the  spine  several  points  of  great  tenderness 
were  discovered.  One  of  these  is  located  at  the  lower 
cervical,  one  at  the  middle  dorsal,  and  one  at  the  lower 
portion  of  the  lumbar  region.  Till  within  a  compara- 
tively recent  period,  patient  has  exhibited  no  hysterical 
symptoms  ;  of  late,  however,  she  has  been  troubled  by 
occasional  attacks,  which  are  evidently  of  an  hyster- 
ical nature.     At  times  is  irritable  and  depressed,  and 


SPINAL  IRRITATION.  167 

at  all  times  she  exhibits  much  susceptibility  to  sensory 
impressions,  and  particularly  to  noises  of  all  kinds. 
Thus,  while  I  was  conversing  with  her,  she  requested 
me  to  arrest  the  pulsations  of  a  faradic  battery,  which, 
she  said,  caused  her  great  annoyance.  Dr.  Simpson 
writes  me  that  the  rumbling  of  a  cart  or  the  sound  of 
hammering  are  quite  unendurable  to  her.  ' '  Medication 
has  done  little  for  her,  electricity  has  done  nothing." 

She  has  had  a  good  deal  of  cervical  erosion,  which 
has  yielded  well  to  the  measures  employed  by  Dr. 
Simpson.  In  spite  of  these  local  benefits,  there  has, 
nevertheless,  been  no  diminution  in  the  severity  of 
the  dorsal  pains.  Menstruation  is  regular,  but  occa- 
sionally accompanied  by  some  pain.  Motions  of  the 
body,  such  as  bending  forwards  or  backwards  or  to- 
wards the  side,  evoke  the  dorsal  pain  or  increase  it. 
The  same  is  true  of  riding  in  a  carriage. 

This  was  substantially  the  condition  of  the  patient 
when  Dr.  Simpson  brought  her  to  my  office  on  the 
fifth  of  April,  1888. 

After  consultation,  it  was  decided,  inasmuch  as  all 
other  remedies  had  failed,  to  resort  to  local  medication 
of  the  cord. 

The  point  selected  for  the  first  injection  was  the 
point  of  tenderness  in  the  lower  lumbar  region, 

A  careful  preliminary  measurement  to  the  trans- 
verse process  having  been  made,  one  hmidred  minims 
of  a  1  i  solution  of  cocaine  were  injected  into  the  pain- 
ful region.  As  I  was  careful  to  thoroughly  refrigerate 
the  painful  area  with  the  rhigolene  spray  before  mak- 
ing the  injection,  the  pain  caused  by  the  puncture 
was  insignificant.  Shortly  after  the  conclusion  of  the 
operation,  the  patient  manifested  great  nervous  excite- 
ment, and  complained  of  sensations  of  tingling  and 


168  HEADACHE  AND  NEURALGIA. 

numbness  in  the  hands  and  feet.  There  were  no 
motor  disturbances  whatever. 

This  condition  of  exaltation  lasted  an  hour  and  a 
half,  when  the  patient  was  able  to  enter  her  carriage 
and  be  driven  to  the  hotel. 

On  the  following  day  I  saw  her  for  a  few  moments, 
and  though  complaining  of  slight  cutaneous  soreness, 
she  declared  that  deep-seated  pain  had  entirely  disap- 
peared in  the  lumbar  region. 

I  have  cited  this  case  as  affording  a  fair  illustration 
of  the  persistent  tendency  of  the  analgesia  evoked  by 
this  application  of  the  drug.  My  case  book  contains 
the  records  of  many  other  cases  in  which  I  have  re- 
sorted to  this  mode  of  treatment.  At  some  future 
time  it  is  my  intention  to  publish  a  tabular  report  of 
these  cases. 


CHAPTEE    XXVII. 

SPINAL  IRRITATION  AND  OTHER  PAINFUL  SYMPTOMS 
CONSEQUENT  UPON  SLIGHT  LOCAL  INJURY  OR  GEN- 
ERAL SHOCK. 

To  my  mind  no  history  of  spinal  irritation  can  be 
regarded  as  complete  that  does  not  include  a  descrip- 
tion of  that  interesting  group  of  symptoms  which  su- 
pervenes as  the  result  either  of  slight  local  traumatism 
or  as  the  sequence  of  a  severe  shake  or  shock.  These 
are  the  cases  so  admirably  described  in  the  fourth 
and  fifth  chapters  of  Erichsen's  classical  work  on 
"  Concussion  of  the  Spiue  " — a  book  the  importance  of 
which  as  a  practical  contribution  to  the  pathology  of 
the  cord  is  not  easily  overestimated.  Few  scientific 
books  have  given  rise  to  more  criticism  than  this  ;  few 
have  been  more  condemned,  few  more  applauded.  To 
state  these  facts  is  but  another  mode  of  proclaiming 
the  epoch-makiug  qualities  of  this  admirable  little 
volume.  For  my  own  part,  I  must  confess  to  but  one 
emotion  after  the  perusal  of  each  successive  edition  of 
this  admirable  contribution  to  neurological  literature — 
that  of  profound  admiration  — a  sentiment  of  such 
proportions,  withal,  that  in  its  presence  the  merest 
thought  of  criticism  would  have  seemed  an  act  of  sac- 
rilege. 

It  is  in  this  spirit  of  full  acceptance,  then,  that  I 
now  propose  to  consider  that  particular  phase  of  spinal 
concussion  which  makes  its  appearance  soon  or  it 
may  be  a  long  time  after  general  shock  or  slight  local 


170  HEADACHE  AND  NEURALGIA. 

injury.  In  order  to  contribute  to  a  greater  fullness 
and  understanding  of  the  subject,  I  shall  cite  cases 
from  my  own  practice  as  well  as  some  of  the  more 
graphic  histories  recorded  by  Mr.  Erichsen. 

Symptoms  — If  a  man  be  suddenly  precipitated  from 
an  elevation,  and  strike  with  violence  upon  the  back, 
or  if  he  be  caught  between  two  seats  of  a  railway  car 
in  the  course  of  an  accident,  so  as  to  bruise,  say  the  lum- 
bar portion  of  his  spine,  a  train  of  grave  symptoms 
may  be  developed,  pointing  to  profound  derangement 
of  the  functions  of  the  cord.  There  may  be  immediate 
paraplegia,  or  some  other  phase  of  paralysis;  there  may 
be  retention  of  urine;  there  may  be  various  forms  of 
paresthesia? — formication,  numbness  or  even  total 
anaesthesia  of  the  affected  parts  ;  or,  paralysis  ac- 
companied by  one  or  more  of  these  phenomena. 
Sometimes,  after  some  febrile  disturbance,  of  short 
duration,  the  symptoms  begin  to  abate,  and  eventual 
complete  recovery  takes  place.  Sometimes,  however, 
the  termination  is  not  so  favorable  ;  there  is  more  or 
less  persistence  of  dorsal  pain,  with  numbness  or  sen- 
sations of  pins  and  needles,  accompanied  by  depression, 
derangements  of  memory  and  other  symptoms  point- 
ing to  profound  implication  of  the  cerebro-spinal  sys- 
tem. The  spinal  tenderness  present  in  such  cases  is 
often  of  an  exquisite  and  obstinate  character— all  the 
resources  of  counter-irritation  and  internal  medication 
being  usually  exhausted  without  appreciable  ameliora- 
tion. Of  late,  I  must  confess,  however,  that  I  have 
experienced  far  less  difficulty  than  formerly  in  control- 
ling this  local  irritation.  I  shall  take  occasion  to  return 
to  this  point  presently. 

If,  in  addition  to  direct  concussion  of  the  spine,  a 
blow  upon  the  head  has  also  been  received,  it  not  in- 
frequently happens  that  in  the  course  of  time  epilep- 


SPINAL  IRRITATION.  171 

tiform  seizures  are  added  to  the  cord  symptoms,  the 
clinical  history  being  somewhat  changed,  and  the  prog- 
nosis thereby  much  clouded.  Finally,  the  blow  upon 
the  spine  may  be  but  slight  or  altogether  absent,  the 
subject  being  merely  thrown  violently  about  as  in  cer- 
tain railway  accidents.  Under  these  circumstances, 
the  symptoms  are  often  slowly  evolved,  and  though 
frequently  less  severe  than  when  the  sequence  of  a 
direct  and  violent  traumatism,  they  nevertheless  par- 
take of  an  insidious  and  lethargic  character,  which 
puts  the  patience  of  both  client  and  physician  to  a 
severe  test. 

Accidents  of  this  class  have  now  become  so  common, 
in  consequence  of  the  manifold  complications  of  modern 
society,  that  attention  to  this  branch  of  pathology  will 
amply  repay  the  practitioner  for  any  additional  trouble 
which  a  proper  familiarization  with  the  subjects  may 
entail.  As  already  noted,  the  painful  localities  along 
the  spine,  so  constant  a  feature  of  such  cases,  are  emi- 
nently worthy  of  the  attention  of  the  practitioner  who 
aspires  not  only  to  a  scientific  diagnosis,  but  to  effective 
therapeutics  as  well. 

At  this  portion  of  the  discussion,  I  believe  that  I 
cannot  do  better  than  cite  a  case  or  two  from  my  own 
practice,  as  well  as  from  the  ample  experience  of  Mr. 
Erichsen. 

H.  C,  merchant,  aged  52  years,  of  strong,  muscu- 
lar constitution,  consulted  me  in  February,  1884,  for  a 
train  of  severe  nervous  symptoms,  which  caused  great 
anxiety  both  to  himself  and  family. 

The  following  are  the  more  prominent  points  in  the 
history  of  the  case: 

One  year  previous  to  consulting  me,  he  had  the  mis- 
fortune to  travel  on  a  railway  train  which  met  with 
a  serious  accident.     The  accident  in  question,  as  it 


172  HEADACHE  AND  NEURALGIA. 

afterwards  appeared,  was  caused  by  the  spreading  of 
the  rails  immediately  in  front  of  a  long  trestle-work. 
Several  of  the  coaches  were  thrown  from  the  trestle 
into  the  water,  many  of  the  occupants  being  caught 
between  the  seats  or  thrown  about  and  severely  injured. 
Others,  again,  were  caught  beneath  the  flying  debris 
and  drowned,  while  yet  others  succeeded  in  making 
their  escape  from  the  windows  of  the  coach.  Among 
the  latter  was  a  distinguished  officer  of  the  United 
States  Army  and  the  gentleman  with  whose  history 
we  are  now  concerned.  Had  the  coach,  after  striking 
the  bottom,  not  rolled  over  upon  its  side,  it  is  probable 
that  those  within,  who  had  not  been  killed  outright, 
would  have  perished  by  drowning.  As  it  was,  a 
large  proportion  of  those  within  the  submerged  cars 
escaped  with  their  lives.  It  cannot  be  said,  however, 
that  these  persons  were  all  unscathed,  for,  though 
the  wounds  received  were  in  most  cases  not  serious, 
the  after-effects  caused  by  the  violent  shaking  were  of 
a  severe  character. 

Among  those  who  developed  severe  symptoms  a  con- 
siderable time  after  the  accident  was  the  gentleman 
who  forms  the  subject  of  this  brief  history.  On  emerg- 
ing from  the  water,  he  became  conscious  that  the 
right  shoulder  and  the  lower  portion  of  the  back  were 
somewhat  stiff  and  sore.  At  the  same  time  he  felt  a 
dull  pain  throughout  the  whole  dorsal  region.  These 
pains  and  the  accompanying  soreness  in  the  shoulder 
soon  disappeared,  however,  and  the  patient  was  be- 
ginning to  regard  himself  as  perfectly  well,  when, 
several  weeks  after  the  accident,  he  complained  of 
numbness  in  the  third,  fourth  and  fifth  fingers,  partic- 
ularly pronounced  in  the  right  hand.  This  numbness 
was  accompanied  by  tremor  of  both  hands,  evoked 
by  every  attempt  to  execute  voluntary  movements. 


SPINAL  IRRITATION.  173 

At  the  same  time  patient  experiences  "dull,  tired" 
feelings  after  walking  even  short  distances,  accom- 
panied hy  great  mental  depression.  Co-existent  with 
the  above  symptoms,  patient  has  remarked  a  progres- 
sive decline  in  his  sexual  powers  ;  so  that,  at  the  time 
of  visiting  me,  his  abilities  in  this  direction  were  nil. 
The  testicles  seemed  unusually  small,  the  scrotum 
was  tightly  contracted  about  them  ;  and,  at  the  same 
time,  the  penis  was  retracted,  so  as  to  expose  only 
about  half  an  inch.  Altogether  the  sexual  apparatus 
presented  the  characteristics  of  that  of  a  young  infant. 
On  examining  the  spine,  no  great  tenderness  could  be 
discovered  ;  but  on  passing  the  wire  brush  along  the 
spinous  processes,  from  the  cervical  region  to  the  sac- 
rum, an  exceedingly  tender  point  was  discovered  in 
the  neighborhood  of  the  eleventh  dorsal  vertebra.  The 
course  of  this  case  was  a  long  and  tedious  one. 

Sleep  being  profoundly  deranged,  patient  was  placed 
on  twenty-grain  doses  of  the  bromides,  to  he  taken 
three  or  four  times  a  day.  Small  doses  of  chloral  were 
also  given  at  night  during  the  first  few  weeks  of  treat- 
ment, combined-  with  the  tincture  of  hyoscyamus. 
Strychnine  was  not  well  borne,  and,  according  to  the 
patient's  statement,  aggravated  the  lumbar  pain 

In  order  to  relieve  the  latter  blisters  were  applied 
throughout  the  painful  region,  but  without  greatly  re- 
lieving the  spinal  soreness.  Prolonged  applications  of 
galvanism  were  more  effectual  in  relieving  the  irrita- 
tion ;  and  accordingly  the  constant  current  was  applied 
every  other  day  for  two  months,  at  the  end  of  which 
time  marked  benefit  had  been  obtained.  The  tin- 
gling and  numbness  of  the  limbs  remained  for  some 
time  longer  ;  but  after  the  lapse  of  four  or  five  months, 
it,   too,   had  entirely  vanished.    Walking    had    also 


174:  HEADACHE   AND   NEURALGIA. 

begun  to  afford  pleasure,  and  could  be  indulged  in 
without  the  fear  of  subsequent  lassitude. 

The  most  difficult  complication  to  combat  in  this 
case  was  the  complete  loss  of  sexual  power,  accom- 
panied by  the  retraction  of  the  organ.  This  retraction 
of  the  penis  was  certainly  phenomenal,  as  already  ob  ■ 
served.  In  order  to  remedy  the  condition,  dry  cupping 
of  the  penis  was  resorted  to,  and  continued  daily  for 
over  three  months,  and  every  other  day  for  the  subse- 
quent four  months.  By  the  aid  of  this  treatment 
combined  with  douches,  the  passage  of  the  cold  sound, 
such  remedies  as  the  chloride  of  gold,  iron  and  the 
coca  preparations,  I  finally  succeeded  in  completely  re- 
storing the  patient's  sexual  powers,  so  much  so,  in  fact, 
that  in  due  time  a  further  addition  was  made  to  his 
family,  the  child,  a  healthy  girl,  weighing  at  birth  over 
nine  pounds. 

This  case  affords  an  excellent  illustration  of  the  slow 
insidious  onset  of  the  affection,  of  the  evolution  of 
severe  and  obstinate  symptoms  without  local  trauma- 
tism of  commensurate  importance,  and  finally  of  the 
ultimate  success  attending  the  treatment  of  what  at 
the  outset  had  all  the  aspects  of  a  hopeless  case. 

The  patient  remained  under  my  immediate  care 
nineteen  months.  At  the  end  of  that  time,  with  the 
exception  of  occasional  attacks  of  depression,  the  cure 
was  complete.  Since  discontinuing  treatment,  I  have 
seen  the  patient  from  time  to  time,  and  some  months 
ago  he  informed  me  that  these  attacks  of  depression 
had  entirely  left  him,  and  that,  in  short,  he  was  as  well 
as  he  had  ever  been  in  his  life. 

The  following  case  of  Mr.  Erichsen,  which  I  cite 
from  his  well-known  work,  somewhat  resembles 
the  above  case,  which  I  have  taken  from  my  own 


SPINAL  IRRITATION.  175 

note  book ;  the  termination  was,  however,  not  so 
fortunate. 

"H.  M.  L.,  a  surgeon,  aged  43,  naturally  a  stout, 
healthy  man,  of  active  professional  habits,  consulted 
me  on  February  22d,  1865.  He  stated  that  on  October 
9th,  1864,  he  was  in  a  railway  collision,  by  which  he 
was  thrown  forwards,  but  without  any  very  great  vio- 
lence. He  received  no  blow  on  the  back,  head,  or 
other  part  of  the  body.  He  was  much  frightened  and 
shaken,  but  did  not  lose  consciousness 

Beyond  a  general  sensation  of  illness,  he  did  not  suf- 
fer much  for  the  first  three  or  four  weeks  after  the 
accident,  but  he  was  not  able  to  attend  to  his  business  ; 
could  not  collect  his  thoughts  sufficiently  for  the  pur- 
pose. 

About  a  month  after  the  accident,  he  began  to  suffer 
from  pain  across  the  loins.  He  could  not  walk  with- 
out great  fatigue.  He  lost  strength  and  flesh,  and  his 
pulse  became  habitually  much  more  frequent  than 
natural,  being  about  98  to  100. 

When  I  saw  him  four  and  a  half  months  after  the 
accident,  he  continued  much  in  the  same  state  ;  was 
quite  unfit  for  business,  and  had  been  obliged  to  relin- 
quish practice  ;  not  owing  to  any  mental  incapacity, 
but  entirely  owing  to  his  bodily  infirmities.  His  mind 
was  quite  clear,  and  his  senses  perfect,  though  over- 
sensitive ;  loud  and  sudden  noises  and  bright  light  be- 
ing particularly  distressing  to  him. 

He  complained  chiefly  of  the  spine.  He  suffered 
constant  pain  in  the  lower  part  of  it,  in  the  lower  dor- 
sal, and  the  lumbar  regions.  He  compared  the  sensa- 
tion there  experienced  to  that  of  a  wedge  or  plug  of 
wood  driven  into  the  spinal  canal.  It  was  a  mixed 
sensation  of  pain  and  distension.  The  spine  generally 
was  tender,  and  the  pain  in  it  was  greatly  increased 


176  HEADACHE  AND  NEURALGIA. 

by  manipulation,  pressure  and  percussion.  It  had  lost 
its  normal  flexibility,  moved  as  a  whole,  so  that  he 
could  not  bend  forward  or  stoop.  There  was  no  pain 
in  the  cervical  region,  or  on  moving  the  head. 

He  complained  of  painful  numbness  and  formications 
in  the  right,  and  occasionally  down  the  left  leg.  The 
legs  were  stiff  and  weak,  especially  the  right  one. 
He  could  not  stand  unsupported  on  this  for  a  moment. 
He  walked  in  a  slow  and  awkward  manner,  straddled, 
and  was  not  able  to  place  the  feet  together.  If  told  to 
stand  on  his  toes,  he  immediately  fell  forward.  He 
had  lost  control  over  the  limbs,  and  did  not  know 
exactly  where  to  place  the  feet.  He  had  a  frequent 
desire  to  pass  water,  suffered  greatly  from  flatus,  and 
had  completely  lost  all  sexual  desire  and  power.  The 
pulse  was  at  98  ;  appetite  bad  ;  digestion  impaired. 

I  saw  this  patient  again  at  Brighton,  toward  the 
end  of  April,  seven  months  after  the  accident,  in  con- 
sultation with  Mr.  Curtis,  and  found  that  his  condition 
had  in  no  way  improved.  I  saw  him  again  in  1878 
with  Mr.  Bellamy.  He  had  tried  to  follow  his  profes- 
sion, but  was  unable  to  do  so.  He  had  partial  paraly- 
sis of  the  musculo- spinal  nerve  of  the  right  arm,  with 
atrophy  of  the  muscles  supplied  by  it.  He  had  partial 
paraplegia.  I  believe  this  mischief  to  have  been  of 
chronic  inflammatory  nature  ;  the  tenderness  of  the 
spine,  the  feeling  of  distension,  the  pain  on  movement, 
and  the  habitually  high  pulse,  pointed  in  this  direc- 
tion." 

The  following  is  another  interesting  case  of  spinal 
concussion  accompanied  by  great  local  tenderness  in 
the  cervical,  dorsal  and  lumbar  regions,  recorded  by 
Mr.  Erichsen.  As  in  the  preceding  case  the  evident 
cause  was  general  shock. 

"Mr.  C.  W.  K,  aged  about  50,  naturally  a  stout, 


SPINAL  IRRITATION.  117 

very  healthy  man,  weighing  nearly  seventeen  stone, 
a  widower,  of  very  active  habits  mentally  and  bodily, 
was  in  a  railway  collision  on  February  3d,  1865.  He 
was  violently  shaken  to  and  fro,  but  received  no  bruise, 
or  any  sign  whatever  of  external  iujury.  He  was 
necessarily  much  alarmed  at  the  time,  but  was  able  to 
proceed  on  his  journey  to  London,  a  distance  of  sev- 
enty or  eighty  miles.  On  his  arrival  in  town  he  felt 
shaken  and  confused,  but  went  about  soniQ  business, 
and  did  not  lay  up  until  a  day  or  two  afterward.  He 
was  then  obliged  to  seek  medical  advice,  and  felt  him- 
self unable  to  attend  to  his  business.  He  slowly  got 
worse,  and  more  out  of  health.  Was  obliged  to  have 
change  of  air  and  scene,  and  gradually,  but  not  unin- 
terruptedly, continued  to  get  worse,  until  I  saw  him 
on  March  26th,  1866,  nearly  fourteen  months  after  the 
accident.  During  this  long  period  he  had  been  under 
the  care  of  various  medical  men  in  different  parts  of 
the  country,  and  had  been  most  attentively  and  assid- 
uously treated  by  Dr.  Elkington,  of  Birmingham,  and 
by  several  others,  as  Dr.  Bell  Fletcher,  Dr.  Gilchrist, 
Mr.  Gamgee,  Mr.  Martin,  etc.  He  had  been  most 
anxious  to  resume  his  business,  which  was  of  an  im- 
portant official  character,  and  had  made  many  attempts 
to  do  so,  but  invariably  found  himself  quite  unfit  for 
it,  and  was  most  reluctantly  compelled  to  relinquish 
it.  When  I  saw  him  at  this  time,  he  was  in  the  fol- 
lowing state  : 

"He  had  lost  about  twenty  pounds  in  weight,  was 
weak,  unable  to  walk  a  quarter  of  a  mile,  or  to  attend 
to  any  business.  His  friends  and  family  stated  that 
he  was  in  all  respects  '  an  altered  man. '  His  diges- 
tion was  impaired,  and  his  pulse  was  never  below  96. 

"  He  complained  of  loss  of  memory,  so  that  he  was 
often  obliged  to  break  off  in  the  midst  of  a  sentence, 


1Y8  HEADACHE  AND  neuralgia. 

not  being  able  to  complete  it.  or  to  recall  what  he  had 
commenced  saying.  His  thoughts  were  confused,  and 
he  could  not  concentrate  his  attention  beyond  a  few 
minutes  upon  any  one  subject.  If  he  attempted  to 
read,  he  was  obliged  to  lay  aside  the  paper  or  book  in 
a  few  minutes,  as  the  letters  became  blurred  and  con- 
fused. If  he  tried  to  write,  he  often  misspelt  the 
commonest  words  ;  but  he  had  no  difficulty  about  fig- 
ures. He  was  troubled  with  horrible  dreams,  and 
waked  up  frightened  and  confused. 

"His  head  was  habitually  hot.  and  often  flushed. 
He  complained  of  a  dull,  confused  sensation  within  it, 
and  of  loud  noises  which  were  constant. 

"The  hearing  of  the  right  ear  was  very  dull.  He 
could  not  hear  the  tick  of  an  ordinary  watch  at  six 
inches  from  it.  The  hearing  of  the  left  ear  was  nor- 
mal ;  he  could  hear  the  tick  at  a  distance  of  about 
twenty  inches.  Noises,  especially  of  a  loud,  sudden  or 
clattering  character,  distressed  him  greatly.  He  could 
not  bear  the  noise  of  his  own  children  at  play. 

"  The  vision  of  the  left  eye  had  been  weak  from 
childhood.  That  of  the  right,  which  had  always  been 
good,  had  become  seriously  impaired  since  the  accident. 
He  suffered  from  muscce  volitantes,  and  saw  a  fixed 
line  or  bar,  vertical  in  direction,  across  the  field  of 
vision.  He  complained  also  of  flashes,  stars,  and  col- 
ored rings. 

"  Light,  even  of  ordinary  day,  was  especially  dis- 
tressing to  him.  In  fact  the  eye  was  so  irritable  that 
he  had  an  abhorrence  of  light.  He  habitually  sat  in  a 
darkened  room,  and  could  not  bear  to  look  at  artificial 
light,  as  of  gas,  candles  or  fire.  This  intolerance  of 
light  gave  a  peculiar'  frowning  expression  to  his  coun- 
tenance. He  knitted  and  depressed  his  brows  in  order 
to  shade  his  eyes.     The  sensations  of  smell  and  taste 


SPINAL  IRRITATION.  179 

seemed  to  be  somewhat  perverted.  He  often  thought 
that  he  smelled  fetid  odors  which  were  not  appreciable 
to  others,  and  lie  had  lost  his  sense  of  taste  to  a  great 
degree.  He  complained  of  a  degree  of  numbness,  and 
of  '  pins  and  needles '  in  the  left  arm  and  leg,  also  of 
pains  in  the  left  leg,  and  a  feeling  of  tightness,  or 
constriction.  All  these  symptoms  were  worst  on  first 
rising  in  the  morning.  He  walked  with  great  diffi- 
culty, and  seldom  without  the  aid  of  a  stick ;  whilst 
going  about  a  room  he  supported  himself  by  taking 
hold  of  the  articles  of  furniture  that  came  in  his  way. 
He  did  not  bring  his  feet  together,  straddled  in  his 
gait,  drew  the  left  leg  slowly  behind  the  right,  moved 
it  stiffly  and  kept  the  foot  ilat  in  walking,  so  that  the 
heel  caught  the  ground  and  the  limb  appeared  to  drag. 
He  had  much  difficulty  in  going  up  and  down  stairs, 
could  not  do  so  without  support. 

"  He  could  stand  on  the  right  leg,  but  if  he  attempted 
to  do  so  on  the  left  it  immediately  bent  and  gave  way 
under  him  so  that  he  fell. 

"  The  spine  was  tender  on  pressure  and  on  percussion 
at  these  points,  viz.,  at  lower  cervical,  in  middle  dor- 
sal, and  in  lumbar  regions.  The  pain  in  these  situa- 
tions was  increased  on  moving  the  body  in  any  direc- 
tion, but  especially  in  the  antero-posterior.  There 
was  a  degree  of  unnatural  rigidity,  of  want  of  flexi- 
bility, about  the  spine,  so  that  he  could  not  bend  the 
body;  he  could  not  stoop  without  falling  forward. 

"On  testing  the  irritability  of  the  muscles  by  gal- 
vanism, it  was  found  to  be  very  markedly  less  in  the 
left  than  in  the  right  leg 

"  The  genito- urinary  regions  were  not  affected.  The 
urine  was  acid,  and  the  bladder  neither  atonic  nor  un- 
duly irritable. 

"  The  opinion  that  I  gave  in  this  case  was  to  the  effect 


180  HEADACHE  AND  NEURALGIA. 

that  the  patient  had  suffered  from  concussion  of  the 
spine,  that  secondary  inflammatory  action  of  a  chronic 
character  had  been  set  up  in  the  meninges  of  the  cord, 
that  there  was  partial  paralysis  of  the  left  leg,  proba- 
bly dependent  on  structural  disease  of  the  cord  itself, 
and  that  the  presence  of  cerebral  symptoms  indicated 
the  existence  of  an  irritability  of  the  brain  and  its 
membranes. 

"  I  saw  the  patient  again  on  April  18th,  1867,  two 
and  a  half  years  after  the  accident.  He  then  suffered 
much  from  pain  in  the  head,  and  in  the  cervical  spine. 
He  was  subject  to  fits  of  continual  depression,  was 
generally  nervous  and  little  fitted  for  his  ordinary 
business,  memory  was  defective,  and  ideas  uncon- 
nected. The  head  felt  hot,  face  had  a  somewhat 
heavy  expressionless  look,  pulse  96  to  98,  digestion 
bad,  urine  phosphatic,  left  leg  numb,  with  occasional 
darts  of  pain  and  sensation  of  '  pins  and  needles. '  It 
was  colder  than  the  right  leg." 

This  case  of  Dr.  Erichsen  is  exceedingly  interesting, 
as  exhibiting  the  profound  and  persistent  disturbances 
of  motility  and  sensibility  consequent  upon  these  severe 
jars,  and  in  the  absence  of  all  evidence  of  direct  trau- 
matism. The  persistence  of  the  accompanying  mental 
disturbances  is  another  interesting  feature.  These 
derangements  of  memory,  of  concentration,  of  the  co- 
ordinating faculty  and  of  consecutiveness  of  argument 
closely  resemble  the  characteristic  group  of  symptoms 
present  in  cerebral  exhaustion.  I  have  often  been 
struck  by  this  resemblance,  and  the  similitude  of  the 
phenomena  has  unavoidably  led  to  speculations  as  to 
a  possible  identity  of  some  of  the  pathological  features 
of  the  two  affections. 

The  following  case,  extracted  from  my  own  note- 
book, is  a  good  illustration  of  some  of  the  milder  phe- 


SPINAL  IRRITATION.  183 

nomena  sometimes  evoked  by  concussion.  As  in  the 
cases  already  cited,  marked  localized  tenderness  of  the 
spine  was  present ;  but  the  condition  was  treated  in  a 
more  direct  and  effective  manner. 

J.  M.,  a  married  man  of  forty  five  years  of  age,  of 
nervous  temperament  and  slight  physique,  consulted 
me  four  years  ago  on  account  of  a  train  of  nervous 
symptoms,  which  caused  him  both  anxiety  and  an- 
noyance.    The  salient  points  in  his  case  were  these  : 

About  eighteen  months  before  consulting  me  he  had 
met  with  an  accident  on  the  Long  Branch  railway. 
He  was  violently  thrown  about  the  car  ;  his  head  was 
cut  and  he  received  a  severe  bruise  in  the  left  lumbar 
region.  On  extricating  himself  from  the  wreckage, 
he  noticed  that  his  legs  felt  "  sleepy,"  and  that  there 
was  a  tingling  sensation  in  the  right  side  of  the  face. 
These  sensations  disappeared  entirely  within  the  fol- 
lowing week,  and  he  was  abundantly  able  to  resume 
the  duties  of  an  active  business  life.  All  went  well 
for  a  time  ;  the  duties  of  society  and  business  received 
a  punctilious  attention,  which  had  never  been  excelled, 
even  when  the  patient  had  been  in  the  enjoyment  of 
the  most  perfect  health.  Some  five  months  subse- 
quent to  the  accident,  however,  he  began  to  complain 
of  great  lassitude,  particularly  during  the  early  morn- 
ing hours.  At  the  same  time  sleep  became  profoundly 
deranged,  and  even  when  he  was  perfectly  certain 
that  he  had  slept  for  a  few  hours  he  complained  that 
his  sleep  " did  him  no  good."  Formerly  of  a  cheerful 
disposition,  he  became  the  victim  of  protracted  periods 
of  depression  ;  his  memory,  of  good  average  strength, 
had  become  so  fickle,  that  he  was  obliged  to  carry  a 
note-book,  in  which  to  record  his  most  trivial  routine 
engagements.  He  also  suffered  from  soreness  in  the 
back  and  occasional  attacks  of  facial  neuralgia, 


182  HEADACHE  AND  NEURALGIA. 

On  examination  his  muscular  system  was  found  to 
be  weak  and  flabby,  his  heart's  action  feeble  and  irreg- 
ular and  his  general  condition  one  of  pronounced 
anaemia.  Pressure  along  the  spinal  column  revealed 
two  points  of  marked  soreness,  the  one  in  the  dorsal, 
the  other  at  the  level  of  the  second  lumbar  vertebra?. 
From  the  first  of  these  tender  spots  radiated,  especially 
on  sudden  changes  in  temperature,  intercostal  pains 
of  considerable  intensity. 

Having  placed  the  patient  on  a  tonic  regimen  and 
prescribed  the  iodide  and  bromide  of  potash,  the  latter 
to  be  taken  in  cumulative  doses  during  the  afternoon 
and  evening,  I  directed  my  attention  to  the  poinf s  of 
tenderness  in  the  spine.  Instead  of  treating  them  by 
the  long  and  tedious  method  of  local  galvanization,  I 
decided  to  try  the  efficacy  of  local  injections  of  a  coca- 
ine solution  of  low  percentage  (1#).  I  had  already 
somewhat  developed  this  mode  of  treatment  by  exper- 
iments on  animals  (dogs  and  rabbits),  and  on  one  occa- 
sion I  had  already  made  use  of  it  in  the  case  of  a  man 
suffering  from  spinal  irritation.  The  injections  were 
made  with  an  ordinary  hypodermic  syringe  and  needle, 
thirty  minims  of  a  Vfo  solution  of  the  hydrochlorate  of 
cocaine  being  deposited  in  the  painful  zone.  Owing 
to  the  possible  danger  of  wounding  the  cord,  I  did  not 
make  these  injections  as  deeply  as  I  desired,  for  at 
that  time  I  had  not  developed  the  technique  of  the 
procedure  sufficiently  to  admit  of  this.  Later,  how- 
ever, I  discovered  a  method  of  performing  this  part  of 
the  operation  in  the  most  perfect  manner,  without 
either  clanger  or  inconvenience  to  the  patient.1  This 
perfected  technique  has  already  been  thoroughly  de- 
scribed in  the  previous  chapter;  and  its  efficacy  abun- 

1  See  previous  chapter.  Also  "  Scientific  American  Supplement" 
for  Sept.  24th,  1887,  and  the  "Medical  Record"  for  March  17th,  1888. 


SPINAL  IRRITATION.  183 

dantly  demonstrated  by  numerous  clinical  histories.  In 
spite  of  the  inevitably  primitive  nature  of  the  proced- 
ure, I  succeeded  in  affording  much  relief  to  the  pa- 
tient ;  so  that,  after  the  injections  had  been  repeated 
a  few  times,  the  soreness  disappeared  entirely. 

When  I  compare  the  promptness  of  the  relief  ob- 
tained in  this  case  with  the  long  course  of  palliative 
treatment  required  in  the  case  detailed  at  the  begin- 
ning of  this  chapter,  I  am  the  more  surprised  that 
greater  efforts  have  not  heretofore  been  made  to  affect 
the  functions  of  the  cord  by  resort  to  more  effective 
and  direct  methods. 

Having  thus  detailed  some  of  the  painful  complica- 
tions often  encountered  in  even  the  milder  phases  of 
concussion  of  the  spine,  it  now  becomes  necessary  to 
leave  this  interesting  portion  of  the  subject ;  for,  it  is 
self-evident  that  to  pursue  the  matter  further  would 
be  to  transcend  the  natural  limitations  of  a  dissertation 
of  this  sort. 

As  to  the  subject  of  local  medication  in  its  truest 
sense,  that  is  the  bringing  of  medicinal  substances 
into  the  immediate  vicinity  of  or  in  direct  contact 
with  the  cord,  in  contradistinction  to  measures  applied 
at  a  distance  from  the  latter,  as  upon  the  integument, 
I  can  only  say  that  judged  by  results,  the  improved 
procedure  is  inevitably  destined  to  play  a  conspicuous 
part  in  the  neuro-therapeutics  of  the  future. 


PART  V. 


Normal  and  Morbid  Sleep. 


CHAPTER  XXVIII. 

CONSIDERATIONS   ON   THE  PHYSIOLOGY   OF   SLEEP. 

I  have  already  had  occasion  to  allude  repeatedly,  in 
different  portions  of  this  work,  to  the  important  part 
which  derangements  of  sleep  play  in  intra  aDd  extra- 
cranial head-aches,  and  indeed  in  all  forms  of  pain. 
Mention  has  also  been  made  of  the  great  benefits  to  be 
derived  from  the  skillful  use  of  prolonged  sleep,  in  the 
treatment  of  all  varieties  of  head-pain. 

A  proper  understanding  of  sleep  is,  therefore,  quite 
as  necessary  to  the  physician  who  would  treat  those 
painful  affections  properly  as  to  the  alienist  engaged  in 
the  management  of  mental  disorders.  The  concluding 
portion  of  this  treatise  will,  therefore,  be  devoted  to 
the  consideration  of  the  more  important  phases  of  nor- 
mal and  morbid  sleep. 

As  a  preliminary  to  the  consideration  of  the  more 
intricate  questions,  a  discussion  of  the  physiological 
factors  involved  will  prove  useful. 

Sleep  may  be  defined  in  general  terms  as  that  state 
of  the  central  nervous  system  in  which  the  higher 
centres  are,  to  a  great  extent,  in  a  condition  of  physi- 
ological quiescence,  with  all  the  consequences  thereby 
implied.  In  its  most  profound  form,  and  probably  in 
it  most  perfect  manifestation,  there  is  a  total  cessation 
of  the  strictly  psychical  functions.  The  automatic  and 
reflex  centres,  on  the  contrary,  are  active,  so  that  the 
functions  dependent  thereon  —such  as  respiration,  cir 
culation,  digestion,  secretion,  etc. — are  regularly  car- 


188  HEADACHE  AND  NEURALGIA. 

ried  on.  Again,  the  re- actions  to  external  excitation 
must  be  considered  as  systematized  reflex  actions,  as 
they  are  in  every  respect  similar  to  the  automatism 
observed  in  decapitated  animals.  Judged  from  an  ex- 
perimental standpoint  there  is  indeed  no  reason  why 
these  phenomena  should  not  occur  even  with  a  certain 
degree  of  apparent  objectiveness,  without  necessitating 
the  intervention  of  the  strictly  psychical  centres. 

During  the  early  history  of  medicine  everything 
pertaining  to  sleep  was  regarded  with  more  or  less 
superstition,  and  the  theories  propounded  respecting 
the  nature  of  the  same  were  as  a  rule  of  the  most  fan- 
tastic nature.  It  is,  indeed,  only  within  comparatively 
recent  years  that  experimental  physiology  has  essayed 
the  solution  of  a  problem,  which  even  to  investigators 
of  ripe  understanding  seemed  little  short  of  hopeless. 
The  difficulties  with  which  the  subject  is  inevitably 
environed  are  certainly  great,  and  scientific  progress 
has  of  necessity  been  slow,  in  spite  of  the  efforts  of 
even  the  most  original  minds.  At  the  present  day,  how- 
ever, a  survey  of  the  investigations  which  have  been 
made  in  this  department  of  phsyco-physiology  cannot 
fail  to  cause  gratification  at  the  substantial  and 
durable  nature  of  the  acquisitions.  Among  the  most 
important  experimental  contributions  to  the  physi- 
ology of  sleep  are  those  which  have  served  to  exhibit 
the  relation  of  the  intra-cranial  blood-stream  to  the 
cerebral  protoplasm. 

There  can  be  no  doubt  that  the  ancients  entertained 
certain  theories  respecting  the  relation  of  the  carotid  cir- 
culation to  the  function  of  sleep.  Thus,  in  an  interest- 
ing paper,  Pilz1  refers  as  follows  to  the  knowledge  pos- 

]  "Zur  Ligatur  der  Arteria  Carotis  Communis,"  von  Dr.  C. 
Pilz,  Langenbeck's  Archives  fur  Klinischie  Chirurgie,  vol.  IX.,  p. 
406.     1868. 


THE    PHYSIOLOGY  OF  SLEEP.  189 

sessecl  by  Rufus  of  Ephesus  respecting  the  influence 
exercised  by  digital  compression  of  the  carotids  upon 
the  function  of  sleep.  "Arterias  per  collum  subentes 
carotides,  id  est  somniferas,  antiquos  nominesse,  quo- 
niam  compressse  hominem  sopore  gravabant. ' ' '  These 
early  accounts  of  compression  are,  however,  enveloped 
in  a  veil  of  uncertainty;  and  whatever  use  the  ancients 
may  have  made  of  the  procedure  seems  to  have  been 
speedily  forgotten  by  subsequent  writers.  At  all 
events,  comparatively  little  is  to  be  found  in  literature 
upon  the  subject  until  the  close  of  the  eighteenth  cen- 
tury, when  Parry,  of  Bath  (1792),  again  directed  the 
attention  of  the  profession  to  the  efficacy  of  digital 
compression  of  the  carotids,  as  a  means  for  the  allevi- 
ation of  convulsive  disorders.  The  publication  of  this 
paper  seems  to  have  added  a  new  impetus  to  the  sub- 
ject; and  the  result  is  a  series  of  papers,  extending 
over  a  period  of  seventy-five  years.  In  1819  Dr.  M. 
Bland  published  some  interesting  cases,  illustrative  of 
the  efficacy  of  digital  compression  of  the  carotids  in 
cerebral  disorders  characterized  by  engorgement. 

Twenty  years  later  Dr.  J.  B  Stroehlin 2  published  an 
article  upon  the  same  subject.  In  an  article  published 
in  1841,  Dr.  Troudeau 3  calls  attention  to  the  great  effi- 
cacy of  digital  compression  of  the  carotids  in  convul- 
sive disorders.  A  case  of  acute  meningitis  is  cited,  in 
which  the  author  essayed  digital  compression  of  the 
carotids  with  good  results. 

Reference  is  also  made  to  the  discussion  respecting 
the  priority  of  the  discovery  of  digital  compression, 
which  ensued  upon  the  publication  of  MM.  Trous- 
seau's, Baudelocque's,  and  Malapert's  papers.     In  the 

1  Morgagni,  de  sedibus  et  caus.  Morb.  epist.  19,  quoted  by  Pilz. 

2  "Medical  Examiner,"  April,  1841. 

3  "Journal  Medico-Chirurgical "  of  November,  1840. 


190  HEADACHE  AND  NEURALGIA, 

paper  of  Dr.  Dezeimeris,  which  appeared  about  the 
same  time,  the  credit  of  the  discovery  of  the  therapeu- 
tic value  of  digital  compression  is  awarded  to  Parry,  of 
Bath.  In  1848  Waller ]  published  an  essay  on  the  uses 
of  digital  compression,  in  which,  while  praising  the 
procedure  in  the  highest  terms,  he  expresses  regret 
that  the  difficulty  often  experienced,  in  adapting  the 
ringers  to  the  contours  of  the  arteries,  should  be  so  great. 

Seven  years  after  the  publication  of  the  paper  of 
Waller,  Fleming 2  instituted  some  experiments,  with  a 
view  to  ascertaining  the  physiological  effects  of  com- 
pression. By  exercising  pressure  with  the  fingers 
upon  the  carotids  this  observer  was  able  to  produce 
sleep  on  several  occasions. 

During  the  same  year  Dr.  T.  W.  Mc Arthur 3  pub- 
lished a  paper  upon  the  therapeutic  effects  of  the  pro- 
cedure, in  which  he  expresses  the  conviction  that  com- 
pression of  the  carotids  is  beneficial  in  at  least  some 
convulsive  diseases. 

In  1860  Durham 4  ascertained  by  direct  observation 
that  the  amount  of  blood  circulating  in  the  brain  is 
reduced  in  quantity  during  sleep.  His  experiments 
were  performed  in  the  following  manner:  A  circular 
opening  was  made  in  the  skull  of  a  dog  with  a  tre- 
phine, care  being  exercised  not  to  cause  injury  to  the 
membranes.  A  portion  of  the  dura  was  then  carefully 
removed,  so  as  to  expose  the  vessels  of  the  pia  mater 
and  a  watch-glass  cemented  over  the  opening. 

1  "Medical  Counsellor,"  September,  1855. 

2  An  article  by  Dr.  Alexander  Fleming,  "British  and  Foreign 
Medico-Chirurgical  Review, "  April,  1855. 

3  "On  Compression  of  the  Carotids — Its  Effects  on  Headache, 
etc.,"  by  Augustus  Waller,  M.D.,  "Journal  of  Psychological  Med- 
icine."    London,  1848. 

4  "The  Physiology  of  Sleep,"  by  Arthur  L.  Durham.  "Guy's 
Hospital  Reports,"  vol.  vi.,  1860. 


THE    PHYSIOLOGY  OF  SLEEP.  191 

When  the  animal  was  awake  the  vessels  of  tne  pia 
were  observed  to  be  moderately  distended,  whereas 
during  sleep  the  brain  was  somewhat  retracted  and 
presented  a  pale  appearance. 

The  contrast  in  the  appearance  of  the  organ  during 
activity  and  repose  is  said  to  have  been  remarkable. 

This  paper  belongs  in  the  category  of  the  most  im- 
portant contributions  to  the  physiology  of  cerebration. 
The  author's  critical  interpretation  of  the  phenom- 
ena is  masterly  and  is  well  worthy  of  careful  perusal. 
This  is  not  the  place,  however,  to  enter  into  an  analysis 
of  the  inferential  data  of  the  paper.  Five  years  after 
the  publication  of  the  experiments  of  Durham,  Dr. 
Guibert1  gave  expression  to  his  views  regarding  the 
value  of  digital  compression  of  the  carotids  as  a  thera- 
peutic agent,  noting  with  regret  the  evident  neglect 
which  this  valuable  procedure  had  met  with  at  the 
hands  of  the  profession. 

In  1869  Hammond 2  published  the  results  of  a  series 
of  experiments,  undertaken  with  a  view  to  ascertain- 
ing the  amount  of  cerebral  pressure  present  during 
sleep,  as  well  as  during  wakfulness.  The  experiments 
were  performed  upon  dogs  and  rabbits,  by  the  aid  of 
an  instrument  called  the  ' '  cephalohsemometer, ' '  in- 
vented by  the  author.  This  appliance  ' '  consists  of  a 
brass  tube,  which  is  screwed  into  a  round  hole  made 

in  the  skull  with  a  trephine Both  ends  of.  the 

tube  are  open;  but  into  the  upper  is  screwed  another 
brass  tube,  the  lower  end  of  which  is  closed  by  a  piece 
of  very  thin  sheet  india-rubber,  and  the  upper  end 
with  a  brass  cap,  into  which  is  fastened  a  glass  tube. 

1  "De  La  Ligature  et  de  la  Compression  des  Artires  Carotides," 
"Union  Medicale,"  January,  1865. 

2  "  New  York  Medical  Gazette  and  Quarterly  Journal  of  Psycho- 
logical Medicine  and  Medical  Jurisprudence,"  January,  1869. 


192  HEADACHE  AND  NEURALGIA. 

.  .  .  The  inner  arrangement  contains  colored  water, 
and  to  the  glass  tube  a  scale  is  affixed.  .  .  .  This 
second  glass  tube  is  screwed  into  the  first,  till  the  thin 
rubber  presses  upon  the  dura  mater,  and  the  level 
of  the  colored  water  stands  at  0,  which  is  in  the  mid- 
dle of  the  scale. ' '  It  was  found  that  when  the  ani- 
mal is  asleep,  the  liquid  falls  in  the  tube,  indicating 
that  a  diminution  in  cerebral  pressure  has  taken  place. 
Now,  since  the  pressure  is  in  direct  proportion  to  the 
quantity  of  blood  circulating  in  the  brain,  diminution 
of  the  former  can  only  take  place  in  consequence  of  a 
reduction  in  the  amount  of  intra-cranial  blood.  When 
the  animal  awakes  the  liquid  in  the  tube  is  seen  to  rise 
at  once.  Thus,  by  virtue  of  the  results  obtained  by 
Hammond,  the  experiments  of  Fleming  and  Durham 
receive  substantial  confirmation. 

Schiff '  has  found  by  direct  measurements  performed 
upon  the  brain,  that  a  local  development  of  heat  takes 
place  in  the  particular  district  where  an  impression  is 
disseminated.  And  he  has  furthermore  ascertained 
that  this  local  development  of  heat  is  a  dynamic  phe- 
nomenon, quite  distinct  from  any  mere  activity  on 
the  part  of  the  circulation.  We  have  in  a  word  to  do 
with  an  evolution  of  heat  in  the  psychical  centres 
which  takes  place  on  the  advent  of  the  sensorial  im- 
pression. The  direct  and  indirect  value  of  these  inves- 
tigations of  Schiff  to  psycho-physiology  it  is  difficult 
to  overestimate. 

Lombard  and  others  have  shown  that  during  active 
mentalization  the  temperature  above  the  skull  rises. 
The  thermo-electric  instrument  employed  by  Lombard 
in  these  investigations  is  extremely  ingenious;  a  de- 
scription of  the  same  is  contained  in  the  "  British  Med. 
Journal,"  1875. 

1  "  Archives  de  Physiologie,"  1870. 


THE  PHYSIOLOGY  OF  SLEEP.  193 

Several  years  ago,  while  yet  entirely  ignorant  of  the 
experimental  researches  of  Fleming  and  Durham,  I 
was  led  by  considerations  of  a  purely  theoretical 
nature  to  inaugurate  a  series  of  experiments  with  the 
object  of  determining  the  effects  produced  by  pressure 
applied  to  the  stems  of  both  carotids.  My  first  at- 
tempts at  compression  were  made  with  the  fingers; 
but  I  soon  became  aware  of  the  inherent  defects  of 
this  method.  Ere  long,  however,  the  thought  sug- 
gested itself  to  me  that  an  instrument  might  be  de- 
vised which  would  effectually  obviate  the  disadvan- 
tages of  the  digital  method. '  Accordingly  after  many 
trials  I  succeeded  in  constructing  an  appliance  with 
which  I  was  not  only  able  to  conduct  some  highly 
instructive  experiments,  but  likewise  to  add  a  chapter 
to  the  therapeutics  of  epilepsy,  acute  mania,  and 
certain  functional  cerebral  disorders,  characterized  by 
vascular  derangements.  Without  entering  into  the 
details  of  these  investigations,  which  have  long  since 
received  extensive  recognition  both  in  this  country  and 
abroad,  I  will  briefly  summarize  the  more  important 
physiological  phenomena  which  they  served  to  exhibit. 
When  pressure  was  made  upon  both  carotids  with  the 
instrument  above  referred  to,  the  first  symptom  which 
attracted  my  attention  was  marked  facial  pallor.  As 
the  degree  of  compression  was  gradually  increased 
there  was  marked  drooping  of  the  eyelids,  accompanied 
by  dizziness.  These  symptoms  were  soon  followed  by 
retardation  of  respiration  and  cardiac  action,  while  at 

1  For  a  description  of  this  instrument  and  for  an  account  of  the 
experiments  performed  with  it  see  "  Medical  Record  "  of  February 
18th,  1882.  Also,  "Carotid  Compression,"  by  J.  Leonard  Corning, 
M.D.;  Anson  D.  F.  Randolph  &  Co.,  New  York,  1882.  Finally: 
"  Electrization  of  the  Sympathetic  and  Pneumogastric  Nerves 
and  Carotid  Compression."  Ibid.  ''New  York  Med.  Jour.,"  Feb. 
22d,  1888. 

13 


194  HEADACHE  AND  NEURALGIA. 

the  same  time,  in  a  considerable  proportion  of  cases, 
the  subjects  complained  of  a  heavy,  drowsy  sensation. 
So  overpowering  was  this  soporific  tendency  in  some 
subjects  that  a  condition  closely  simulating  if  not 
actually  equivalent  to  sleep  was  produced.  In  very 
anaemic  persons  it  was  possible  to  produce  an  instan- 
taneous condition  of  syncope;  while  in  several  cases  of 
acute  congestive  mania  I  was  enabled  to  produce  a 
condition  which,  as  far  as  I  was  able  to  ascertain,  was 
identical  with  natural  sleep.  With  the  idea  of  elimi- 
nating all  sources  of  error  which  might  be  conceived 
as  arising  from  contiguous  nerve-stems,  I  had  con- 
structed a  large  cylindrical  apparatus,  by  means  of 
which  it  was  possible  to  enclose  the  lower  extremities 
hermetically.  An  air-pump,  attached  to  the  appara- 
tus by  means  of  a  rubber  hose,  enabled  the  experimen- 
ter to  exhaust  the  cylinder  to  any  desired  degree.  With 
this  apparatus,  I  was  enabled  to  produce  retardation 
of  respiration,  and  cardiac  action,  as  well  as  marked 
soporific  phenomena  in  some  cases.1 

Finally,  the  experiments  of  Nounyma  and  J.  Schrie- 
ber2  have  shown  that,  when  the  amount  of  intra-cranial 
blood  is  increased,  there  is  a  corresponding  diminution 
in  the  quantity  of  cerebro  spinal  fluid  within  the  skull, 

1  For  an  account  of  these  and  other  investigations  vide  "  Medical 
Record,"  Feb.  18th,  1882;  an  article  on  "  Sleep,"  "  Medical  Record," 
July,  1882.  A  monograph  on  "  Carotid  Compression,"  Anson  D. 
F.  Randolph  &  Co.,  New  York,  1882.  A  paper  read  before  the 
New  York  Neurological  Society  June  6th,  1882,  and  published  in 
the  "Philadelphia  News"  of  June  17th,  1882,  and  in  the  "Ameri- 
can Journal  of  Neurology  and  Psychiatry,  1882.  Also  a  paper  on 
"  Electrization  of  the  Sympathetic  and  Pneumogastric  Nerves," 
with  Simultaneous  Bilateral  Compression  of  the  Carotids,  "New 
York  Medical  Journal,"  Feb.  23, 1884. 

2Uber  Gehirndruch  von  Nounyma  and  J.  Schreiber,  Leipzig: 
F.  C.  W.  Vogel,  1881. 


THE   PHYSIOLOGY   OF   SLEEP.  195 

owing  to  a  deviation  of  the  liquid  in  the  direction  of 
the  spinal  subarachnoid  space. 

These  experiments  prove  beyond  question  that  the 
degree  of  sanguineous  irrigation  of  the  encephalon  is 
in  direct  proportion  to  the  amount  of  functional  activ- 
ity of  the  organ.  When  the  activity  of  the  brain  is 
greatest,  the  hyperaemia  of  the  meninges  obtains  a 
maximum  degree  of  intensity;  whereas,  during  the 
functional  quiescence  of  sleep,  the  amount  of  blood 
circulating  in  the  vessels  of  the  pia  mater  is  at  a  min- 
imum. That  this  relation  of  the  blood-stream  to  the 
cerebral  plasma  is  not  one  of  mere  concomitance,  but 
rather  the  outgrowth  of  the  functional  necessities  of 
the  cerebral  cell  itself,  is  proven  by  the  immediate 
diminution  in  the  intensity  of  brain  function,  which 
ensues  upon  compression  of  the  carotids.  Even  where 
the  protoplasm  of  the  ganglia  is  in  an  unstable  condi- 
tion, as  in  epilepsy,  it  is  possible,  as  proven  by  the  ex- 
perimental observations  of  Stroehlin,  Trudeau,  Waller, 
McArthur  and  myself,  to  arrest  the  convulsions  to 
which  the  unusually  explosive  condition  of  the  cere- 
bral parenchyma  gives  rise,  by  pressure  upon  the  stems 
of  the  common  carotid  arteries. 

The  ebb  and  flow  of  the  intra-cranial  blood-stream, 
then,  is  contingent  upon  the  functional  necessities  of 
the  ganglia.  Cerebration  is  essentially  a  process  of 
oxydation.  Inversely,  sleep  is  that  condition  in 
which  oxydation  within  the  ganglia  is  at  a  mini- 
mum. The  unconsciousness,  which  is  the  character- 
istic feature  of  sleep  is,  therefore,  nothing  more  than 
the  expression  of  a  decline  in  the  processes  of  meta- 
morphosis within  the  brain  cell.  The  local  cerebral 
anaemia,  the  retarded  heart  beat,  and  the  infrequent 
respiration  are  at  once  the  direct  consequent  of,  and 


196  HEADACHE  AND  NEURALGIA. 

indispensable  requisite  to,  the  decline  of  cerebral  meta- 
morphosis. 

As  to  the  more  intimate  nature  of  the  metamorpho- 
sis incident  to  cerebration,  but  little  is  known  with 
certainty.  Hammond J  has  conducted  a  series  of  care- 
ful urinal  analyses,  for  the  purpose  of  ascertaining  the 
changes  in  the  composition  of  the  urine  incident  to 
increased  mentalization.  From  these  experiments  he 
is  led  to  draw  the  following  conclusions: 

(1.)  That  increased  mental  exertion  augments  the 
quantity  of  urine. 

(2.)  That,  by  its  influence,  the  urea,  chlorine,  and 
phosphoric  and  sulphuric  acids  are  increased  in  quan- 
tity. 

(3.)  That  the  uric  acid,  on  the  contrary,  is  very 
materially  reduced  in  amount. 

(4.)  That  diminished  intellectual  exertion  produces 
effects  directly  contrary  to  all  the  above. 

More  recently,  Byasson 2  has  demonstrated  that  the 
activity  of  the  ganglia  is  accompanied  by  an  expendi- 
ture of  phosphorized  material,  and,  furthermore,  that 
this  waste  product  of  brain  activity  is  eliminated  from 
the  organism  through  the  urine,  in  the  form  of  phos- 
phates and  sulphates.  In  addition  this  observer  found 
that  the  amount  of  phosphates  and  sulphates  secreted 
stands  in  a  certain  ratio  to  the  quantity  of  mental 
energy  expended;  and  that,  in  a  word,  the  above 
waste  products  could  be  utilized  as  a  measure  of  the 
amount  of  brain  work  accomplished  in  a  given  length 
of  time.3 

1  "Urological  Contributions,"  "The  American  Journal  of  the 
Medical  Sciences,"  April,  1856. 

2  "  Journ.  d'anat.  de  Robin,"  1869. 

3  For  a  more  detailed  account  of  these  experiments  than  is  ad- 
missible in  a  work  of  this  character,  see  my  monograph  on  "  Brain 
Exhaustion,"  D.  Appleton  &  Co.,  New  York, 


THE   PHYSIOLOGY   OP  SLEEP.  197 

Dr.  Kobert  J.  Edes  has  very  recently  published  a 
series  of  experiments  by  which  it  is  sought  to  prove 
"that  the  amount  of  phosphates  derived  from  the 
metamorphosis  of  brain-tissue  in  the  condition  of  phy- 
siological activity  is  so  small,  in  comparison  with  that 
from  the  system  generally,  that  it  has  no  perceptible 
effect  on  the  total  of  phosphates  found  in  the  urine." 

Owing  to  the  lack  of  system  observed  in  these  ex- 
periments with  regard  to  diet,  physical  exercise  and 
sleeping,  it  is  impossible  to  accept  the  results  obtained 
as  either  confirmatory  of  or  opposed  to  the  researches 
of  Byasson  and  others.  Until,  therefore,  more  sub- 
stantial scientific  evidence  to  the  contrary  is  forth- 
coming, we  must  accept  the  conclusions  arrived  at  by 
these  gentlemen.  A  more  extended  criticism  of  these 
experiments  has  been  given  in  my  monograph  on 
cerebral  exhaustion,  previously  referred  to,  and  I  shall 
therefore  abstain  from  pursuing  the  discussion  further 
on  the  present  occasion. 

If,  then,  it  be  admitted,  that  the  greater  the  expen- 
diture of  cerebral  force  the  greater  is  the  excretion  of 
phosphates  and  sulphates,  we  are  bound  to  assume 
conversely  that  the  quantity  of  these  products  de- 
creases proportionately  with  a  decline  in  mentaliza- 
tion.  Since,  therefore,  sleep  is  the  expression  of  a 
minimum  of  cerebration,  it  follows,  as  a  natural  conse- 
quence, that  during  its  continuance,  the  excretion  of 
phosphates  and  sulphates  must  be  smaller  in  amount 
than  under  any  other  circumstances. 

It  is  true,  nevertheless,  that  if  dreaming  and  uncon- 
scious cerebration  be  accepted  as  accompaniments  of 
normal  sleep,  the  integrity  of  the  above  argument  is 
vitiated  to  a  certain  extent;  for  doubtless  both  dream- 
ing and  unconscious  cerebration  represent  the  output 
of    no  little  energy  on  the  part  of    the  cerebrum. 


198  HEADACHE  AND  NEURALGIA. 

Hence  the  great  lassitude  observable  after  sleeping  in 
those  who  are  addicted  to  excessive  dreaming,  night- 
mare or  unconscious  cerebration.  For  my  own  part, 
I  cannot  consider  any  one  of  these  last-named  phe- 
nomena as  constituting  an  accompaniment  of  the  nor- 
mal type  of  sleep  strictly  considered.  As  above  inti- 
mated, nothing  is  more  certain  than  that  those  who 
suffer  from  nightmare,  persistent  dreaming  and  un- 
conscious cerebration  awake  from  sleep  far  less 
refreshed  than  those  who  suffer  from  none  of  these 
psychological  encumbrances.  I  could  cite  many  cases 
occurring  in  my  own  experience  illustrative  of  this 
fact.  A  common  complaint  on  the  part  of  such  indi- 
viduals is  that  although  they  have  slept  a  sufficient 
number  of  hours,  they  nevertheless  experience  no 
benefit,  and  awake  totally  unrefreshed,  and  entirely 
unprepared  for  the  activities  of  the  day.  Dreaming, 
unconscious  cerebration,  and  nightmare,  will  there- 
fore be  considered,  in  the  following  discussion,  among 
the  obvious,  though  less  serious  anomalies  of  sleep. 
To  sum  up  the  evidence,  already  adduced,  we  find 
that  the  essential  factors  of  sleep  are: 

1.  Exhaustion  of  the  available  energy  of  the  cerebral 
cell,  by  which  it  is  to  be  understood  that  the  explosive 
material,  hoarded  up  during  a  former  period  of  uncon- 
ciousness, has  become  oxydized,  and  is  no  longer  in  a 
condition  to  support  the  chemical  process  incident  to 
function.  As  a  consequence  we  have  a  decline  of  all 
the  intellectual  processes,  and  finally  complete  loss  of 
consciousness,  accompanied  by  a  fall  in  temperature.1 

1  As  shown  by  Shiff,  the  rise  in  temperature,  which  accompanies 
intellection,  is  not  alone  attributable  to  the  local  hyperemia,  but 
must  be  ascribed  in  part,  at  least,  to  the  increased  metamorphosis 
which  takes  place  within  the  cell  itself.  Inversely,  it  is  evident, 
that  the  fall  in  local  temperature^  observable  during  sleep,  is  not 


THE  PHYSIOLOGY  OF  SLEEP.  199 

2.  Retrocession  of  the  intra-cranial  blood-stream, 
resulting  in  more  or  less  pronounced  anaemia  of  the 
ganglia. 

3.  Decline  of  oxydation  within  the  ganglia. 

4.  Retardation  of  the  heart's  action. 

5.  Decline  in  the  rapidity  of  respiration. 

6.  Concomitant  with  the  decline  of  oxydation  a 
gradual  re-accumulation  of  explosive  material  takes 
place  within  the  ganglia. 

From  a  consideration  of  the  foregoing  physiological 
factors,  it  will  be  seen  that  during  sleep  the  processes 
of  integration  predominate  over  those  of  disintegra- 
tion; whereas  during  waking  the  opposite  condition 
prevails.  The  most  important  f miction  of  sleep  then 
is  to  counteract  the  ganglionic  waste  incident  to 
cerebration. 

A  thorough  comprehension  of  the  physiological  sig- 
nificance of  sleep  is  absolutely  indispensable  alike  to 
the  rational  understanding  and  treatment  of  all  forms 
of  mental  derangement.  Moreover,  the  various  phases 
of  insomnia  are  only  amenable  to  rational  treatment, 
by  virtue  of  a  correct  appreciation  of  the  various  phy- 
siological factors  of  normal  sleep. 

CLASSIFICATION    OF    INSOMNIA. 

The  following  division  of  insomnia  into  two  princi- 
pal groups  is  justifiable,  at  least  from  a  clinical  stand- 
point. Moreover,  while  fulfilling  the  exigencies  of 
practice  it  will  be  found  to  be  in  essential  harmony 
with  the  physio -pathology  involved.  Insomnia  may 
be  divided,  then,  into  an  idiopathic  and  into  a  symp- 
tomatic  variety.     Idiopathic    (primary)  insomnia    is 

alone  a  consequence  of  the  anaemia,  but  must  be  ascribed  in  part 
to  a  decline  in  the  intensity  of  the  dynamic  processes  within  the 
cells  themselves. 


200  HEADACHE  AND  NEURALGIA. 

that  form  of  sleeplessness,  the  predisposing  cause  of 
which  cannot  be  traced  to  any  particular  source  extra- 
neous to  the  brain  itself.  Symptomatic  (secondary) 
insomnia  is  that  form  of  the  disorder  which  may  be 
observed  in  the  course  of  many  acute  and  chronic  dis- 
orders. Under  this  head  may  also  be  considered  that 
form  of  the  affection  which  arises  from  a  more  or  less 
severe  degree  of  pain. 


CHAPTER  XXIX. 

IDIOPATHIC   INSOMNIA. 

Etiology. — The  most  important  causes  of  this  pre- 
eminently important  variety  of  the  affection  are  ex- 
cessive emotional  disturbances  combined  with  overtax- 
ation of  the  intellectual  faculties. 

Among  the  former  are  profound  sorrow,  jealousy, 
fear,  heavy  responsibility,  disappointed  ambition,  sus- 
pense, sudden  pecuniary  losses,  and  in  short  every 
factor  which  acts  with  sudden  intensity  upon  the  cen- 
tres of  ideation  and  emotion. 

There  is  probably  no  single  cause  so  liable  to  result, 
if  unchecked,  in  permanent  impairment  of  the  cere- 
bral apparatus,  as  this  form  of  insomnia.  It  is  a  fact 
of  the  highest  theoretic  and  practical  importance,  that 
not  only  do  the  lesser  forms  of  functional  impairment 
of  the  intellectual  mechanism  begin  with  some  de- 
rangement of  sleep,  but  also  those  graver  forms  of 
mental  derangement,  usually  included  under  the  des- 
ignation of  insanity,  are  almost  invariably  preceded  by 
more  or  less  chronic  insomnia.  The  wear  and  tear 
incident  to  business  and  professional  competition,  as 
well  as  the  involved  nature  of  the  social  conditions  of 
modern  life  have  much  to  do  with  the  prevalence  of 
the  disorder.  The  above  proposition  is  amply  substan- 
tiated by  the  statistics  of  insane  asylums  and  hospi- 
tals. In  view  of  these  facts  it  is  hardly  necessary  to 
insist  upon  the  important  relation  sustained  by  dis- 
orders of  sleep  to  cerebral  economics  and  pathology. 


202  HEADACHE  AND  NEURALGIA. 

Symptoms.  — These  consist  in  great  lassitude  during 
the  day,  coupled  with  a  high  degree  of  irritability, 
which  is  particularly  well  marked  in  the  morning. 
The  skin  has  usually  a  dead,  sallow  appearance  and 
the  eyes  are  sunken  and  devoid  of  their  normal  lustre. 
The  urine  is  often  scant  and  highly  colored,  and  a  con- 
stipated habit  is  the  rule.  Sometimes,  however,  the 
subject  is  afflicted  by  an  obstinate  diarrhoea,  which 
contributes  not  a  little  towards  his  general  enfeeble- 
ment.  So  great  is  the  lassitude  in  severe  cases  that 
the  patient  reclines  upon  the  sofa  the  greater  part  of 
the  day,  or  wanders  about  the  apartment,  unable  to 
summon  energy  sufficient  to  perform  even  the  most 
trivial  task.  Uncontrollable  yawning  is  present  in 
almost  every  case.  When  expostulated  with,  on  ac- 
count of  his  listlessness.  the  subject  becomes  morose 
and  sullen,  refusing  in  the  most  peremptory  manner 
to  listen  to  the  counsel  of  those  about  him.  The 
small  ills  of  life  assume  commanding  proportions,  and 
even  the  most  trivial  occurrences  are  distorted,  and 
magnified  to  an  inordinate  degree.  On  retiring  the 
subject  is  unable  to  sleep.  He  tosses  from  side  to  side, 
removes  the  bed-clothes,  changes  his  position  contin- 
ually in  the  vain  endeavor  to  become  unconscious. 
The  peripheral  irritation  occasioned  by  his  contortions 
only  serves  to  perpetuate  the  condition  of  cerebral 
erethism.  When,  as  frequently  happens,  sleep  at  last 
supervenes,  it  is  no  longer  physiological  in  character, 
but,  on  the  contrary,  perverted  by  dreams  and  uncon- 
scious cerebration  to  such  a  degree  that  it  affords  little 
or  no  refreshment.  Daylight  finds  the  individual 
completely  prostrated,  and  unable  to  resume  his  accus- 
tomed activities  with  the  requisite  amount  of  energy. 

Under  these  circumstances  resort  is  had  to  stimulants 
of  all.  kinds.     Strong  coffee,  tea,  brandy  and  even  mor- 


IDIOPATHIC  INSOMNIA..  203 

phine  are  tried,  with  the  hope  of  affording  a  renewal 
of  vigor.  But  the  relief  obtained  is  at  most  transi- 
tory in  character,  and  the  reaction,  which  inevitably 
follows,  leaves  the  subject  in  a  far  worse  condition 
than  before.  Where  the  temperament  of  the  patient 
is  abnormally  emotional,  the  insomnia  is  of  a  far 
graver  character  than  where  the  cast  of  mind  is  es- 
sentially intellectual.  Adversity,  worry  and  suspense 
are  not  well  endured  by  such  persons;  and  even  trivial 
disappointments  give  rise  to  all  manner  of  dismal 
forebodings.  The  cares  of  the  day,  instead  of  being 
abandoned  at  bed-time,  take  entire  possession  of  the 
mind,  and  effectually  exclude  sleep.  It  is,  moreover, 
an  unfortunate  circumstance  that  the  occupations 
usually  preferred  by  this  class  of  individuals  are  such 
as  appeal  powerfully  to  the  emotions;  and  thus  the 
mind  is  kept  in  a  perpetual  state  of  erethism. 

On  the  other  hand,  those  in  whom  the  ratiocina- 
tive  faculties  assume  great  prominence,  though  sub- 
ject at  times  to  attacks  of  insomnia,  are  far  less  liable 
to  become  victims  of  chronic  wakefulness  than  those 
in  whom  the  emotional  faculties  are  predominant. 
Moreover,  the  insomnia  peculiar  to  the  former  class 
of  persons  is  not  usually  accompanied  by  the  extreme 
mental  irritation  which  is  so  constant  and  painful  a 
symptom  of  the  emotional  type  of  sleeplessness. 

A  vivid  imagination  is  also  extremely  prone  to  ag- 
gravate an  attack  of  insomnia.  The  fancy,  instead  of 
becoming  gradually  subdued,  until  the  supervention 
of  unconsciousness,  increases  in  activity;  while  myriads 
of  fantastic  thoughts  crowd  upon  the  mind  in  endless 
procession,  and  baffle  every  attempt  at  repose.  Those 
possessed  of  great  imaginative  powers  and  strong 
emotions  are  particularly  dependent  upon  sleep.  De- 
prived of  the  latter,  they  become  listless,  irritable  and 


204  HEADACHE  AND  NEURALGIA. 

emaciated;  and  in  an  incredibly  short  time  the  ardor 
of  even  the  most  sanguine  dispositions  is  entirely 
quenched.  During  the  early  part  of  the  night  such 
persons  lie  awake  for  several  hours,  tormented  by  a 
constant  succession  of  thoughts  and  emotions  of  the 
most  varied  character,  and  not  till  towards  morning 
do  they  usually  succeed  in  falling  asleep.  This  sleep, 
though  short  in  duration,  is  far  from  physiological  in 
character,  being  accompanied  in  most  instances  by  a 
succession  of  morbid  dreams,  which  are  th.3  direct  out- 
growth of  the  previous  condition  of  mental  extrava- 
gance. 

On  awaking,  complaint  is  made  of  sensations  of 
heaviness,  of  head  pains,  which  may  be  variously  loca- 
ted, or  of  a  feeling  of  constriction  about  the  forehead. 
Sometimes  a  sensation  of  distention  is  noticed  in  the 
region  of  the  vertex,  which  may  or  may  not  be  accom- 
panied by  pain. 

There  is  a  large  class  of  persons  in  cities,  employed 
in  hotels,  theatres,  and  other  public  places  of  resort, 
who  from  the  nature  of  their  employment  are  com- 
pelled to  remain  awake  during  the  whole  or  a  greater 
portion  of  the  night.  It  is  the  habit  of  these  individ- 
uals to  seek  to  compensate  for  the  loss  of  sleep  entailed 
by  their  various  nocturnal  employments,  by  resort  to 
day  sleep.  Such  repose,  is,  however,  both  as  regards 
duration  and  quality,  far  inferior  to  the  normal  sleep 
enjoyed  at  night;  and  the  persons  who  are  compelled 
to  resort  to  it  are  rarely  if  ever  able  to  compete  in 
energy  or  endurance  with  those  whose  employments 
permit  them  to  retire  soon  after  sunset.  They  be- 
come either  sallow  and  emaciated  in  appearance,  or 
pale  and  flabby,  especially  when  addicted  to  the  use  of 
alcoholic  stimulants.  As  to  the  sleep  itself,  not  only 
is  it  deficient,  as  we  have  seen,  in  ultimate  restorative 


IDIOPATHIC  INSOMNIA.  205 

effect,  but  also  with  regard  to  quality.  Morbid 
dreams,  unconscious  cerebration,  and  nightmare  are 
the  usual  accompaniments  of  day  sleep.  In  the  ma- 
jority of  cases,  persons  whose  only  alternative  was  the 
form  of  sleep  just  described,  have  been  obliged,  after 
the  lapse  of  but  a  few  years  or  even  months,  to  desist 
from  the  nocturnal  employment  and  adopt  some  other 
form  of  occupation. 


CHAPTEK  XXX. 

SECONDAEY  INSOMNIA. 

SLEEPLESSNESS    ARISING     FROM     IRRITATION     OF     THE     CEN- 
TRIPETAL  NERVES. 

In  order  to  insure  the  most  perfect  form  of  natural 
sleep,  there  should  be,  as  far  as  possible,  an  absence  of 
sensory  impressions.  "When  there  exist  neither  irrita- 
ting disorders  within  the  body  nor  upon  its  surface, 
and  when  no  impressions  are  transmitted  through  the 
special  senses,  it  is  evident  that  the  requirements  of  the 
above  proposition  are  fulfilled.  During  normal  sleep, 
it  is  true,  the  receptive  centres  are  blunted  because  of 
the  exhausting  effects  of  the  previous  stage  of  activ- 
ity. As  a  consequence,  moderate  sensory  impressions, 
which  during  the  waking  condition  would  have  led  to 
active  perception,  leave  no  imprint  upon  the  exhausted 
protoplasm.  When,  however,  impressions  of  consid- 
erable intensity  are  transmitted  to  the  exhausted  re- 
ceptive centres,  the  latter  become  irritated  and  aroused 
from  the  lethargy  consequent  upon  exhaustion,  and 
finally  the  entire  cerebral  mechanism  is  aroused — the 
individual  is  awakened. 

This  is  the  essental  morbid  physiology  of  what  I 
have  considered  under  the  head  of  secondary  or  symp- 
tomatic insomnia. 

Dr.  Kobert  J.  Graves '  has  given  an  excellent  de- 

1  Clinical  Lectures,  by  Dr.  Robert  J.  Graves,  second  American 
Edition:  Ed.  Barrington  &  Geo.  D.  Howell,  Philadelphia,  1842, 


SECONDARY    INSOMNIA.  207 

scription  of  the  insomnia  produced  by  the  application 

of  blisters.  Such  cases  are  practically  experimental  cor- 
roboration of  the  views  advanced  by  myself  with  regard 
to  the  nature  of  symptomatic  insomnia.  Moreover, 
they  serve  to  illustrate  the  anti-soporific  effects  pro- 
duced by  irritation  of  the  peripheral  organs  of  centri- 
petal nerves.  In  speaking  upon  this  subject,  Dr. 
Graves  observes: — "  The  bad  effects  on  the  nervous  sys- 
tem occasionally  produced  by  the  application  of  blis- 
ters, are  somewhat  analogous  to  those  which  result 
from  wounds  and  other  external  injuries,  and  to  be 
accounted  for  on  the  same  principle.  .  .  .  Wounds 
and  injuries  sometimes  make  an  impression  on  the 
nervous  system  by  no  means  proportioned  to  the  im  • 
portance  of  the  injured  organ  to  life,  or  to  the  extent 
of  the  mischief.  .  .  .  An  injury  produced  by  a  body 
which  strikes  the  sentient  extremities  of  the  nerves 
with  great  force  will  sometimes  produce  very  remark- 
able effects  on  the  system.  .  .  .  Thus  a  musket  ball 
striking  a  limb  may,  without  wounding  any  great 
artery  or  nerve,  or  destroying  any  part  of  importance 
to  life,  produce  a  train  of  nervous  symptoms  of  an  ex- 
traordinary character.  The  person,  without  feeling 
much  pain,  and  scarcely  knowing  that  he  has  been 
wounded,  without  being  terrified,  or  having  his  imag- 
ination excited  by  an  apprehended  danger,  turns 
pale,  gets  a  tendency  to  faint,  and  sometimes  actually 
dies  from  the  impression  made  on  the  nervous  system. 
...  In  the  same  way  an  external  injury  (or  even  a 
comparatively  slight  impression1)  reacting  on  the 
nerves  (and  centres  of  perception)  may  bring  on  high 
mental  excitement,  delirium,  and  a  total  privation  of 
sleep.  The  delirium  and  sleeplessness  arising  from 
blisters  is  by  no  means  an  uncommon  disease." 

'  The  parenthetical  remarks  are  mine,  J.  L.  C. 


208  HEADACHE  AND  NEURALGIA. 

The  majority  of  cases  of  secondary  insomnia  are 
traceable  to  some  irritative  process  affecting  the  ter- 
minal organs  of  the  centripetal  nerves,  or  to  some  acute 
or  chronic  form  of  organic  disease,  by  which  a  vast 
number  of  sensory  nerves  are  kept  in  a  more  or  less 
continuous  state  of  irritation. 

If  the  pathological  physiology  advanced  by  myself  be 
accepted,  it  will  readily  be  understood  why  acute  and 
chronic  affections  should  produce  obstinate  sleepless- 
ness, even  where  no  considerable  degree  of  pain  is 
present.  Furthermore,  the  views  expressed  by  Dr. 
Graves  concur  with  mine  in  every  particular. 

Among  the  diseases  which  most  frequently  produce 
insomnia  are:  Cutaneous  affections,  acute  and  chronic 
pulmonary  diseases,  neural  hyperesthesia  (neuralgia), 
stomachic  disorders,  syphilis  and  fevers.  It  is  suffi- 
ciently obvious  also  that  pain,  whatever  may  be  its 
origin,  is  one  of  the  most  prolific  sources,  if  not  the 
most  prolific  cause  of  insomnia.  Again  certain  forms 
of  kidney  and  hepatic  troubles  may  produce  more  or 
less  protracted  wakefulness. 

Without  pursuing  the  subject  in  all  its  ramifications, 
which  would  be  a  useless  loss  of  time  as  far  as  any 
practical  benefit  is  concerned,  it  will  be  well  to  bestow 
a  glance  upon  the  various  forms  of  morbid  dreams, 
which  are  so  constant  an  accompaniment  in  almost  all 
cases  of  wakefulness. 


CHAPTER   XXXI. 
CONSIDERATIONS   ON   DREAMS. 

The  composition  of  dreams  is  determined  in  great 
measure  by  the  individuality  of  the  subject,  and  by  the 
sum  total  of  the  impressions  of  which  he  has  been  the 
recipient.  As  to  the  contents  of  a  particular  dream, 
it  is  a  matter  of  common  experience  that  the  acciden- 
tal emotions  and  ideas,  present  in  the  mind  previous  to 
retiring,  exert  a  determining  influence  upon  its  consti- 
tution. All  the  multifarious  factors  of  the  mental  life 
of  the  individual— all  that  he  has  felt,  willed,,  or  expe- 
rienced—may be  revived  in  his  dreams. 

The  impressions  which  may  give  rise  to  dreams  by 
acting  upon  the  individual  during  sleep  are  of  various 
kinds.  In  the  first  place  the  impressions  which  act 
upon  the  central  ganglia  through  the  five  senses  very 
often  give  rise  to  dreams.1  Secondly,  the  subjective 
excitation  of  the  senses,  as  well  as  muscular  sensa- 
tions and  general  impressions  of  the  most  varied  char- 
acter, may  result  in  the  production  of  dreams.  Even 
where  a  certain  sense  is  closed  to  outward  impressions, 
the  individual  is  by  no  means  necessarily  deprived  of 
the  sensations  and  ideas  arising  from  the  same  when 
in  a  normal  condition.  Thus  Esquirol 2  mentions  the 
case  of  a  man  who  when  forty-one  years  of  age  was 
afflicted  by  double  cataract,  and  who  nevertheless  be- 

1  Vide  the  opinions  entertained  by  Schopenhauer  relative  to  this 
point,  Parerg.  und.  Paralipom.  Leipzig,  1877. 

2  Cited  by  Radestock, 

14 


210  HEADACHE   AND   NEtTRALGlA. 

came  enraged  with  persons  whom  he  supposed  he  saw. 
Biester  relates  that  there  lived  in  Anspach,  not  many 
years  since,  an  old  midwife  entirely  blind,  who  com- 
plained that  she  was  troubled  not  by  ghosts,  but  by 
the  frequent  appearance  of  animals  and  men.  The 
apparitions  were  quite  as  vivid  as  though  she  were  in 
full  possession  of  the  power  of  vision.1 

Malposition  of  the  body,  indigestion  and  other 
causes  which  tend  to  impede  the  circulation  are  said 
by  some  to  give  rise  to  cardiac  palpitations,  difficulty 
of  respiration,  and,  when  the  phenomena  are  very  pro- 
nounced, to  nightmare.  While  willing  to  admit  that 
such  may  often  be  the  case,  I  feel  compelled  to  affirm 
that  I  have  known  of  many  cases  of  nightmare  in 
which  no  such  factors  as  malposition  of  the  body  in 
bed  or  indigestion  could  be  ascertained.  Indeed  the 
only  possible  assignable  cause  of  the  disorder  was  a 
condition  of  cerebral  irritation  or  exhaustion.  It  is 
my  firm  belief  that  precisely  as  palpitations  and  diffi- 
culty of  respiration  are  produced  by  excessive  emotions 
during  waking,  so  the  same  derangements  may  be 
caused  during  sleeping  as  a  result  of  the  excessive 
emotional  disturbances  often  present  during  dreams. 
Where  the  subject  of  dreams  is  of  a  neurotic  tempera- 
ment or  a  sufferer  from  cerebral  exhaustion  or  irritabil- 
ity, the  influence  of  purely  psychological  disturbances 
(whether  occurring  during  waking  or  as  accidents  of 
sleep)  upon  the  respiratory,  cardiac  and  general  bodily 
functions,  is  far  grea/ter  than  in  those  of  more  robust 
constitution.  Among  ancient  and  mediaeval  peo- 
ples the  frightful  phenomena  of  nightmare  were  as 
cribed  to  some  supernatural  agency,  and  demonology 
and  witchcraft  have  at  all  times  received  substantial 
support  from  the  same  frightful  source.  The  inhabi- 
1  Berliner  Monatsschrift,  October,  1800. 


CONSIDERATIONS   ON  DREAMS.  211 

tants  of  New  Zealand  regard  the  apparitions  of  dreams 
as  hurtful  deities,  and  similar  opinions  are  entertained 
by  some  of  the  tribes  of  Central  America  and  by  some 
of  the  inhabitants  of  the  coast  of  Africa. 

So  excellent  an  authority  as  Augustin  believes  that 
the  visits  of  the  incubi  have  been  attested  by  so  main- 
competent  witnesses,  that  a  further  denial  of  the  fact 
is  impossible. 

The  following  narrative,  recorded  by  Raoul  Glaber, 
embodies  such  a  graphic  illustration  of  nightmare, 
that  I  give  it  in  full,  in  lieu  of  further  description: 
' '  One  night  towards  early  morning,  I  saw,  sitting  at 
the  foot  of  my  bed  a  little  monster  of  hardly  human 
shape.  It  appeared  to  me  to  be  of  medium  size,  thin 
necked,  emaciated  form,  with  black  eyes  and  a  narrow 
wrinkled  forehead.  The  nose  was  broad,  the  mouth 
large,  the  lips  thick,  and  the  chin  short  and  sharp.  A 
goat's  beard,  straight  pointed  ears,  dirty  dry  hair,  dog's 
teeth,  pointed  occiput,  projecting  breast,  hump  back, 
withered  loins,  and  dirty  clothes  completed  the  picture. 
It  seized  the  side  of  my  bed,  shook  it  with  fearful 
strength,  and  said:  Thou  shalt  not  remain  here  long. 
Upon  that  I  awoke  terribly  frightened,  sprang  out  of 
my  bed,  ran  to  the  cloister,  and  cast  myself  before  the 
altar,  where  I  remained  for  a  long  time  petrified  with 
fright."  l  Guibert  de  Noigent  relates:  "  One  night  I 
was  awakened  by  difficulty  of  breathing;  I  believe  it 
was  winter.  I  lay  in"  my  bed  and  considered  myself 
safe  in  the  glow  of  a  brightly  burning  lamp.  Sud- 
denly the  deep  stillness  seemed  to  be  broken  by  a 
myriad  of  voices  proceeding  from  above.  At  the 
same  time  my  head  seemed  to  be  wrapped,  as  it  were, 
in  a  dream;  I  lost  the  use  of  my  senses  and  thought  I 
saw  a  certain  dead  person  appear  before  me,  and  a 

"Op.  cit,,  p.  127. 


212  HEADACHE  AND  NEURALGIA. 

loud  voice  declared  that  he  had  been  murdered  in  his 
bath.  Frightened  by  this  apparition,  I  sprang  from 
my  resting  place  with  a  loud  cry,  the  lamp  was  extin- 
guished, and  in  the  midst  of  the  horrible  darkness  T 
saw  the  demon  in  his  true  form  standing  by  the 
bed." 

In  our  own  day  the  substance  of  dreams  is  some- 
what less  demoniacal  in  character;  and  witches,  devils 
and  hags  have  given  place  to  the  denizens  of  the  jun- 
gle and  the  forest.  Tigers,  boa-constrictors,  scorpions, 
centipedes,  all  the  fear-inspiring  shapes  which  adorn 
the  pages  of  a  hideous  zoology,  are  the  companions  of 
the  modern  dreamer.  But  the  repertory  of  dismal 
shapes  is  by  no  means  confined  to  natural  history. 
Theology,  history,  romantic  literature,  love  and  hate,  all 
afford  material  for  dreams.  Sometimes  those  afflicted 
with  nightmare  experience  a  sensation  as  though  the 
chest  were  bound  down  with  chains,  or  as  though  a 
huge  stone  were  rolled  upon  the  breast.  All  such 
sensations  are  the  outgrowth  of  the  disturbances  of 
respiration  to  which  reference  has  already  been  made. 
Since  nightmare  usually  occurs  shortly  after  midnight, 
Prout  is  led  to  the  conclusion,  that  the  cause  of  this 
form  of  dreaming  is  to  be  ascribed  to  the  condition  of 
the  blood,  which  at  that  time  according  to  his  observa- 
tions is  saturated  with  carbonic  acid  to  a  maximum 
degree.  Macnish  found  that  he  was  attacked  by 
nightmare  when  he  sat  in  an  arm-chair  or  when  his 
head  reclined  upon  the  table,  or  even  when  lying  upon 
his  side. '  Such  a  position  as  the  one  first  described  is 
well  calculated  to  cause  interference  with  the  freedom 
of  the  inspiratory  act;  and  thus  an  undue  accumula- 
tion of  carbonic  acid  in  the  blood  is  the  inevitable 

1  Der  Schlaf   in  Allen  seinen   Gestalten,  (translated  from  the 
English)  Leipzig,  1835, 


CONSIDERATIONS   ON   DREAMS.  213 

result.  J.  Bonier1  has  shown  experimentally,  that 
interference  with  the  ingress  and  egress  of  air  to  and 
from  the  air  passages  may  result  in  the  production  of 
the  phenomena  of  nightmare.  In  order  to  prove  this 
he  fastened  the  bedclothes  over  the  mouth  and  nose  of 
a  person  in  deep  slumber,  so  that  respiration  was  par- 
tially interrupted.  Upon  this  it  was  observed  that  the 
face  of  the  sleeper  became  suffused  and  his  respiration 
retarded;  while  the  respiratory  muscles  were  thrown 
into  violent  action  and  the  veins  of  the  neck  became 
greatly  swollen.  After  awaking  the  person  experi- 
mented upon  related  that  he  had  suffered  from  the 
symptoms  of  nightmare,  the  apparition  appearing  in 
the  form  of  an  ugly  monster.  Severe  catarrhal  affec- 
tions, when  coupled  with  a  somewhat  heavy  evening 
meal,  may  give  rise  to  difficulty  of  respiration  and 
morbid  dreams,  if  we  are  to  accept  the  testimony  of 
Binz.2 

But  dreams  are  by  no  means  always  characterized 
by  the  pressure  of  the  terrible  or  hateful.  On  the  con- 
trary they  present  not  only  the  shadows,  but  also  the 
brightest  side  of  real  and  imaginary  existence.  Only 
in  dreams  do  the  majority  of  mankind  ever  succeed  in 
realizing  their  most  fondly  cherished  wishes,  their 
highest  ideals.  Many  a  talent,  many  a  genius  con- 
demned by  the  relentless  circumstance  of  environment 
from  adequate  expression,  has  found  in  dreams  a 
temporary  emancipation  from  the  thraldom  of  reality. 
Kiches,  power,  perfect  health,  achievement,  are  all  pos- 
sible in  dreams,  and  only  thus  are  the  majority  of  man- 
kind ever  to  know  them.  If  dreams  were  invariably 
the  outgrowth  of  impressions  and  ideas  originating  in 

'Das   Alpdriicken,  seine   Begriindung  und  Verhiitung-Wurz- 
burg,  1855. 
2  Cited  by  Rhadestock,  Op.  cit.,  p.  130. 


214  HEADACHE  AND  NEURALGIA. 

the  occupations  of  the  previous  day,  then,  indeed  our 
nocturnal  reveries  would  be  far  from  agreeable.  The 
circumstances,  however,  are  fortunately  very  different. 
It  is  a  matter  of  experience,  in  fact,  that  dreams  are 
often  built  up  of  remote  ideas,  the  very  remembrance 
of  which  has  long  since  faded  from  memory.  The 
resuscitation  of  these  dim  ideas  from  the  lower  strata 
of  consciousness,  as  a  consequence  of  central  stimula- 
tion, is  certainly  one  of  the  marvels  of  psychology. 
Moreover,  owing  to  a  further  automatic  excitation,  the 
reproduced  ideas  are  interwoven  with  other  revived 
impressions,  so  that  the  dream  receives  the  most  varie- 
gated coloring. 


CHAPTER  XXXII. 

THE    DIFFERENCE    BETWEEN   DREAMS  AND 
WAKING  THOUGHT. 

From  what  has  already  been  said  with  regard  to  the 
constitution  of  dreams,  it  will  be  seen  that  a  scientific 
classification  of  the  phenomena  is  beset  with  unusual 
difficulty.  So  manifold,  and,  at  the  same  time,  so 
devoid  of  all  sequence  and  coherence  are  the  manifes- 
tations of  dreams,  that  the  comparison  of  the  latter 
with  insanity  seems  in  a  certain  sense  justifiable. 

Pfaff,  Krauss,  Artemidoros,  Purkinje,  Spitta  and 
Nicol  have  sought  to  classify  the  phenomena  of 
dreams;  but,  with  the  exception  of  the  subdivisions  of 
Spitta,  these  systems  possess  little  practical  value. 

The  most  rational  method  of  approaching  the  sub- 
ject is  that  which  is  based  upon  a  consideration  of  the 
elements  of  dreams,  and  the  laws  governing  the  asso- 
ciation of  ideas. 

A  glance  at  the  composition  of  dreams  reveals  the 
fact  that  tli3  distinguishing  feature  of  individual  con- 
ceptions is  their  great  exaggeration  and  vividness, 
which  is  doubtless  attributable  to  the  inordinate  excit- 
ability of  the  higher  centres.  Comparatively  insignifi- 
cant impressions  transmitted  through  the  centripetal 
nerves  are  sufficient  to  arouse  a  series  of  the  most  ex- 
aggerated conceptions.  The  crackling  of  a  dry  floor 
becomes  the  tramp  of  the  assassin,  the  moonbeams 
falling  upon  the  eyelids  are  magnified  to  the  dignity  of 
a  conflagration;   while  the  rustling  of  leaves  or  the 


216  HEADACHE  AND  NEURALGIA. 

gentle  sighing  of  the  wind  becomes  the  roaring  of  a 
tornado.  An  insignificant  irritation,  such  as  the  bite 
of  a  mosquito,  gives  rise  to  a  positive  sensation  of 
pain,  and  a  slight  tickling  sensation  in  the  throat 
causes  a  feeling  of  suffocation. 

It  is  a  noteworthy  circumstance,  and  one  difficult  of 
explanation,  that  the  exaggerated  conceptions  and 
emotions  of  dreams  are  far  less  liable  to  result  in  seri- 
ous detriment  to  the  organism  than  the  corresponding 
perturbations  of  the  waking  condition.  Thus  sudden 
and  violent  grief  during  waking  has  frequently  re- 
sulted in  immediate  death;  and  even  unexpected  emo- 
tions of  intense  pleasure  have  been  known  to  result 
fatally.  A  soldier  returning  from  the  battle-field  is 
suddenly  apprised  of  the  death  of  his  mother;  and 
although  inured  to  the  hardships  and  terrors  of  the 
campaign,  is  unable  to  withstand  the  effects  of  the 
sudden  mental  contest,  and  falls  dead,  as  though  smit- 
ten by  one  of  his  own  bullets.  A  poor  laborer,  accus- 
tomed to  severe  toil,  is  informed  that  a  relative,  of 
whose  very  existence  he  was  perhaps  unaware,  has 
died  and  bequeathed  to  him  a  competency,  which  will 
render  him  independent  for  the  remainder  of  his  days. 
Instead  of  manifesting  joy  he  becomes  insane  or  dies. 
The  examples  are  legion.  Barely,  however,  are  simi- 
lar effects  witnessed  even  after  the  most  severe  attacks 
of  nightmare. 

Although  we  are  unable,  by  a  mere  flat  of  the  will, 
to  cause  a  cessation  of  our  conceptions,  we  are  yet  able 
to  control,  within  certain  limits,  the  direction  of  our 
thoughts.  What  is  possible  in  the  waking  condition, 
however,  becomes  impossible  for  the  erratic  cerebra- 
tion of  sleep.  The  conceptions  arising  during  dreams 
admit  of  no  guidance;  the  only  governing  influence 
being  the  law  of  the  mutual  relation  of  ideas.     As  a 


DREAMS   AND    WAKLVfj   THOUGHT.  217 

matter  of  fact,  however,  the  impressions  received  be- 
fore retiring,  as  well  as  the  focalization  of  the  thoughts 
in  a  certain  direction  for  a  protracted  period  of  time 
generally  have  a  marked  influence  upon  the  composi- 
tion of  the  dreams  of  the  individual. 

Thus  the  financier  whose  mind  has  long  been  occu- 
pied with  apprehensive  speculations,  will  naturally 
dream  of  accounts,  dollars  and  cents,  and  compound 
interest;  whereas  the  captain  of  a  ship  is  more  liable  to 
be  troubled  by  nocturnal  visions  of  sea-serpents  and 
shipwreck.  It  will  thus  be  seen  that,  although  we  can 
exercise  no  volitional  effect  upon  the  composition  of 
our  dreams,  in  the  sense  that  we  give  direction  to  our 
waking  thoughts;  we  may,  nevertheless,  by  throwing 
the  energies  of  the  mind  in  a  given  direction,  before 
retiring  exert  a  predetermining  influence  upon  the 
character  of  our  nocturnal  reveries. 

I  have  been  thus  explicit,  as  the  subject  is  an  impor- 
tant one  from  a  therapeutic  standpoint. 

The  rapid  evolution  of  conceptions  during  dreams  is 
favorable  to  the  development  of  new  psychological 
combinations.  This  fact  explains  the  frequent,  but, 
at  first  sight,  inexplicable  circumstance  of  a  high  order 
of  rhythmical  intellection  occurring  during  dreams, 
Poems,  musical  compositions,  and  philosophic  epi- 
grams have  been  compared,  and  even  complicated  in- 
ventions conceived  during  dreams.  As  a  rule,  how- 
ever, these  nocturnal  achievements  cannot  stand  the 
test  of  daylight;  and  even  the  most  superficial  logic 
serves  to  reveal  their  extravagance  and  worthless- 
ness.  The  capacity  for  forming  correct  inferences 
and  judgments  is,  in  fact,  greatly  reduced  during 
dreams,  owing  to  the  volatile  nature  of  the  concep- 
tions. 
The  feeling  of  personality,  the  "I,"  is  the  result  of 


218  HEADACHE  AND  NEURALGIA. 

a  summation  of  all  the  psychical  activities,  feelings, 
volitional  activity,  etc.  In  the  construction  of  the  "  I " 
two  factors  are  principally  concerned.  First,  the 
permanent  conceptions  formed  by  ourselves,  and 
which  are  the  outgrowth  of  our  motor  and  "general" 
sensations,  and  of  the  memories  (and  their  associa- 
tions) resulting  from  the  repetition  of  external  impres- 
sions. Secondly,  the  attention  or  active  apperception. 
Now,  since  in  dreams  the  last  named  factor  of  the 
"I"  assumes  a  passive  form,  the  reunion  of  various 
groups  of  conceptions  under  one  uniform  head  is  inter- 
fered with,  by  reason  of  the  chaotic  perception  and 
remembrance  of  fragmentary  portions  of  the  former 
(the  conceptions).1  As  a  consequence  of  the  dimin- 
ished attention,  then,  the  feeling  of  individuality,  the 
sensation  of  the  "I."  which  is  so  characteristic  a  fea- 
ture of  the  waking  condition,  is  in  dreams  reduced  to 
the  last  degree. 

The  foregoing  are  the  more  important  points  of  dif- 
ference between  the  psychology  of  dreams  and  that  of 
the  waking  condition. 

If,  in  treating  the  subject  somewhat  in  extenso,  I 
have  rendered  myself  liable  to  the  charge  of  undue 
prolixity,  I  can  only  plead  in  extenuation  the  great  im- 
portance of  the  subject  to  a  true  understanding  of  both 
the  pathology  and  therapeutics  of  sleep. 

It  is  precisely  pain,  in  its  various  manifestations, 
which  serves  quite  as  much  as  psychical  difficulties  to 
cause  derangements  of  sleep.  To  deal  successfully, 
therefore,  with  these  painful  conditions,  one  must 
have  a  thorough  understanding  of  sleep  and  its  de- 
rangements. 

1  Rhadestock,  Op.  cit.,  p.  157. 


CHAPTER  XXXIII. 

MOEBID   SOMNOLENCE. 

In  the  previous  portion  of  this  discussion  we  have 
described  at  some  length  the  various  conditions  which 
tend  to  reduce  the  amount  of  sleep  normally  required 
by  the  organism.  It  now  remains  to  consider  briefly 
that  condition  in  which  the  duration  of  the  sleeping 
period  is  abnormally  increased. 

Any  one  who  has  paid  special  attention  to  the  mat- 
ter, will  be  able  to  recall  the  cases  of  individuals  who, 
by  reason  of  long  sleeping  or  on  account  of  a  general 
drowsy  habit,  have  become  known  to  their  acquain- 
tances as  lazy,  thriftless  members  of  society.  And  yet, 
such  persons  are  frequently  far  more  deserving  of 
compassion  than  of  censure;  for  a  closer  insight  re- 
veals the  fact  that  their  inactivity  is  neither  the  result 
of  defective  auibition  nor  feeble  volition,  but  is  rather 
the  outgrowth  of  morbid  physiological  conditions 
wholly  beyond  their  control. 

Here  is  an  illustration  in  point :  A  lady,  for  whose 
intelligence  and  Christian  character  I  entertain  the 
highest  respect,  consulted  me  some  time  since  with  re- 
gard to  her  husband,  a  man  who,  up  to  within  a  com- 
paratively recent  period,  had  been  exceptionally  active 
in  business.  Of  late,  however,  he  had  become  "ab- 
sent "  in  manner,  and  had  besides  developed  habits  of 
extraordinary  lethargy.  In  former  times  he  was  in 
the  habit  of  retiring  about  eleven  o'clock  ;  now  he 
sought  his  bed  at  nine,   where  he  remained    until 


220  HEADACHE  AND  NEURALGIA. 

eleven  or  twelve  o'clock  the  next  morning.  Instead 
of  exhibiting  his  former  vivacity,  he  remained  dur- 
ing this  brief  period  of  wakefulness,  if  wakefulness  it 
could  be  called,  in  a  condition  of  apathy,  like  one  over- 
come with  fatigue  and  about  to  fall  asleep  at  any 
moment. 

Such  conditions  as  this  are  doubtless  familiar  to 
most  physicians  who  have  devoted  special  attention  to 
the  physiological  questions  pertaining  to  sleep. 

The  following  classical  cases,  reported  by  Robert 
Macnish,  are  extreme  illustrations  of  morbid  somno- 
lence: 

"The  case  of  Elizabeth  Perkins  is  remarkable. 
In  the  year  1788,  she  fell  into  a  profound  slumber, 
from  which  nothing  could  arouse  her,  and  remained 
in  this  state  for  between  eleven  and  twelve  days,  when 
she  awoke  of  her  own  accord,  to  the  great  joy  of  her 
relatives,  and  wonder  of  the  neighborhood.  On  re- 
covering she  went  about  her  usual  business;  but  this 
was  only  for  a  short  period,  for  in  a  week  after  she 
relapsed  again  into  a  sleep  which  lasted  some  days. 
She  continued,  with  occasional  intervals  of  wakeful- 
ness, in  a  dozing  state  for  several  months. ' ' 

"  The  case  of  Elizabeth  Armitage  of  Woodhouse, 
near  Leeds,  may  also  be  mentioned.  The  age  of  this 
person  was  sixty-nine  years.  She  had  been  for  several 
months  in  a  decline,  during  which  she  had  taken  very 
little  sustenance,  when  she  fell  into  a  state  of  lethargic 
stupor,  on  ths  morning  of  the  1st  of  July,  1827,  in 
which  condition  she  remained,  without  uttering  one 
word,  receiving  any  food,  or  showing  any  signs  of  life, 
except  breathing,  which  was  at  times  almost  imper- 
ceptible. In  this  state  she  continued  for  eight  days, 
when  she  expired  without  a  groan." 

One  of  the  most  extraordinary  instances  of  excessive 


MORBID    SOMNOLENCE.  221 

sleep,  is  that  of  the  lady  of  Nismes,  published  in  1777, 
in  the  "  Memoirs  of  the  Royal  Academy  of  Sciences  of 
Berlin."  "Her  attacks  of  sleep  took  place  periodi- 
cally at  sunrise  and  about  noon.  The  first  continued 
till  within  a  short  time  of  the  accession  of  the  second, 
and  the  second  till  between  seven  and  eight  in  the 
evening,  when  she  awoke,  and  continued  so  till  the 
next  sunrise.  The  most  extraordinary  fact  connected 
with  this  case  is,  that  the  first  attack  commenced 
always  at  daybreak,  whatever  might  be  the  season  of 
the  year,  and  the  other  always  immediately  after 
twelve  o'clock.  During  the  brief  interval  of  wakeful- 
ness, which  ensued  shortly  after  noon,  she  took  a  little 
broth,  which  she  had  only  time  to  do,  when  the  second 
attack  returned  upon  her,  and  kept  her  asleep  till  the 
evening.  Her  sleep  was  remarkably  profound,  and 
had  all  the  characters  of  complete  insensibility,  with 
the  exception  of  a  feeble  respiration,  and  a  weak  but 
regular  movement  of  the  pulse.  The  most  singular 
fact  connected  with  her  remains  to  be  mentioned. 
When  the  disorder  had  lasted  six  months,  and  then 
ceased,  she  had  an  interval  of  perfect  health  for  the 
same  length  of  time.  When  it  lasted  one  year,  the 
subsequent  interval  was  of  equal  duration.  The  af- 
fection at  last  wore  gradually  away;  and  she  lived 
entirely  free  of  it  for  many  years  a  (iter.  She  died  in 
the  eighty-first  year  of  her  age,  of  dropsy,  a  complaint 
which  had  no  connection  with  her  preceding  disorder. ' ' 
Of  the  pathology  of  these  strange  cases  we  know 
nothing;  nor  can  we  form  an  estimate  of  their  causa- 
tion. The  most  that  we  can  say  is  that  in  certain 
cases  of  extreme  exhaustion  or  intoxication  (due  to 
renal  difficulty,  etc.),  certain  somewhat  analogous  con- 
ditions may  be  provoked.  The  comparison  is  at  most, 
however,  but  a  crude  one. 


CHAPTER  XXXIV. 

SOME  GENEKAL  OBSEKVATIONS  ON  THE  TKEAT- 
MENT   OF   INSOMNIA. 

We  have  already  had  occasion  to  refer  to  the  im- 
portant relations  existing  between  derangements  of 
the  function  of  sleep  and  mental  disorders.  But  not 
only  has  it  been  shown  that  sleeplessness  is  one  of  the 
concomitants  of  insanity;  for,  we  have  also  seen  that 
it  is  an  important  factor  of  most  painful  maladies,  and 
particularly  of  that  variety  of  pain  which  is  traceable 
either  to  morbid  conditions  within  the  skull  or  such  as 
are  located  outside  of  it. 

Facts  of  this  kind  point  clearly  enough  to  the  im- 
portance of  possessing  some  knowledge  regarding  this 
matter  of  sleep;  indeed  it  is  quite  inconceivable  that 
one  should  be  able  to  do  much  for  the  painful  affec- 
tions which  we  have  been  considering  without  such 
knowledge.  I  shall,  therefore,  offer  no  apology  for 
recording  a  few  of  the  more  important  principles 
underlying  the  treatment  of  insomnia. 

In  the  first  place,  then,  when  we  are  confronted 
with  some  one  of  the  painful  conditions  described  in 
previous  portions  of  this  work,  we  should  at  once 
make  a  careful  investigation  into  the  habits,  bodily 
condition,  and  possible  hereditary  influences  of  our 
patient. 

If  we  find  that  he  is  a  night -worker  of  long  stand- 
ing, we  should  attempt  to  gradually  abate  the  vicious 
habit;  should  we  find  that  the  patient  has  formerly 


THE    TREATMENT   OF   INSOMNIA.  223 

been  of  a  robust  habit,  and  has  suddenly  or  even 
gradually  lost  flesh,  inquiry  should  immediately  be 
made  as  to  the  existence  of  some  form  of  excess  or 
wasting  disorder,  so  that  we  may  put  a  stop  to  the 
one  and  address  our  skill  to  the  amelioration  of  the 
other. 

Should,  on  the  other  hand,  a  history  of  syphilis  or 
scrofula  be  forthcoming,  we  shall  at  once  know  what 
we  have  to  do,  if  we  aspire  to  achieve  fundamental 
results. 

There  is  nothing  in  these  painful  conditions  more 
significant  than  a  sudden  variation  in  the  weight  or 
circulatory  conditions  of  the  patient.  For  example, 
we  are  called  to  see  a  young  married  woman  suffering 
from  some  form  of  head-pain.  Her  complexion  is 
pale  and  sallow ;  she  complains  of  sleeping  poorly ;  she 
has  had  a  miscarriage,  or  it  may  be  that  she  has  suf- 
fered from  leucorrhcea  or  catarrh  of  the  cervix. 

In  such  a  case  as  this  there  are  two  conditions  which 
strike  us  at  once — loss  of  weight  and  small,  compressi- 
ble pulse.  Where  this  duo  exists,  more  particularly  if 
the  subject  be  of  neurotic  temperament,  we  are  certain 
to  have  an  exacerbation  of  some  form  of  head  pain 
with  its  baneful  accompaniment,  sleeplessness. 

Take  the  exactly  opposite  condition  of  a  man  who 
has  gained  flesh  rapidly.  In  a  considerable  proportion 
of  such  cases  the  history  of  alcoholic  excesses,  with 
its  accompanying  stasis  of  the  cerebral  blood  stream,  is 
forthcoming.  At  the  same  time  we  learn  that  the 
patient  is  a  sufferer  from  cerebral  hyperaemia,  with 
its  consequent  symptoms  of  irritability,  depression, 
vertigo,  headache  and  insomnia.  Here  are  two  dia- 
metrically opposed  conditions.  In  the  case  of  the 
woman  we  have  general  anaemia,  with  consequent 
impoverishment  of  the  entire  nervous  system;  in  the 


224  HEADACHE  AND  NEURALGIA. 

man  we  have  engorgement,  passive  expansion  of  the 
cerebral  capillaries  with  consequent  turgescence  of  the 
cerebral  circulation. 

To  treat  these  two  cases  in  a  similar  ma/rmer,  to  pin 
our  faith  exclusively  to  mere  sedation  by  chemicals, 
would  be  simply  to  ignore  the  appositeness  of  the 
physiological  circumstances  with  which  we  have  to 
deal.  And  yet,  these  are  precisely  the  things  which 
are  most  systematically  ignored;  indeed  one  may  say, 
that  ninety-nine  cases  of  headache  with  insomnia  are 
attacked  through  the  medium  of  the  apothecary's 
shop,  without  any  regard  whatever  to  special  hygienic 
indications. 

Under  the  special  headings  of  anaemic  and  hyperae- 
mic  headache,  I  have  already  discussed  the  means  to 
be  resorted  to  for  the  relief  of  the  circulatory  derange- 
ments, which  play  such  an  important  part  in  the  two 
affections.  All  that  I  then  said  regarding  the  appli- 
cability of  baths,  both  warm  and  cold,  as  well  as  what 
was  stated  regarding  the  Russian  and  Turkish  baths, 
applies  with  equal  force  to  the  treatment  of  the  anae- 
mic and  hyperaemic  varieties  of  insomnia.  To  repeat,  in 
detail,  what  was  then  said,  would  be  but  a  repetition  of 
what  has  already  been  thoroughly  discussed;  I  would 
therefore  merely  observe  that  the  two  principles  to  be 
borne  in  mind  in  the  treatment  of  these  cases  of 
insomnia  with  circulatory  disturbances,  are  first  of  all 
to  correct  the  latter  by  appropriate  means,  and 
secondly,  while  so  doing,  to  address  our  efforts  to 
calming  the  irritated  cerebral  protoplasm.  The  second 
part  of  the  problem  is  best  accomplished  by  the  use  of 
chemical  substances,  which,  having  an  affinity  for  the 
cerebral  substance,  tend  by  uniting  with  it  to  interfere 
to  some  extent  with  that  metamorphosis  which  is 
essential  to  function.     Such  chemical  substances  are 


THE   TREATMENT    OP   INSOMNIA.  225 

the  so-called  narcotics  and  sedatives,  of  which  more  or 
less  has  already  been  said  in  earlier  portions  of  this 
work.  But,  while  it  would,  therefore,  be  a  work  of 
supererogation  to  enter  again  into  details  regarding 
these  substances,  I  desire  to  give  a  general  hint  or  two 
respecting  their  employment,  in  connection  Avith  in- 
somnia. 

To  begin  then  with  the  bromides,  that  group  of 
substances  so  important  in  the  treatment  of  nervous 
affections  of  a  functional  character,  I  would  observe 
that  these  remedies  should  be  employed  with  a  view 
to  exerting  a  gradual  sedative  action  upon  the  central 
nervous  system,  so  that  a  predisposition  to  slumber 
may  be  induced.  They  should  therefore  be  given 
during  the  day,  and  preferably  during  the  latter  portion 
of  it,  their  administration  being  in  fact  continued  until 
shortly  before  the  patient  betakes  himself  to  bed.  A 
moderate  dose  of  chloral,  or  the  tincture  of  hyoscya- 
mus,  or  both  combined,  as  in  the  preparation  known 
as  bromidia,  may  then  be  given,  so  as  to  materially 
augment,  at  the  critical  moment,  the  drowsy  predis- 
position. 

We  have  here  the  key  to  the  secret  of  obtaining 
results  in  the  treatment  of  insomnia,  whether  the 
condition  be  found  in  conjunction  with  mental  de- 
rangement, or  whether  it  be  an  accompanying  com- 
plication of  a  painful  affection,  or,  in  short,  whatever 
the  predisposing  factors  may  be. 

But  this  is  not  enough.     Were  we  to  rest  content 

with  the  chemical  treatment  of  sleeplessness,  we  should 

be  in  grievous  error;  and  yet  this  is  precisely  what 

is    constantly  being  advocated  in  print  and  in  the 

lecture-room.     We  must  look  deeper;   we  must  go  to 

the  bottom  of  the  morbid  problem,  with  which  we  are 

confronted,  so  that,  having  recognized   it,  we  may 
15 


226  HEADACHE  AND  NEURALGIA. 

combat  it  with  all  the  resources  at  our  disposal.  If  we 
have  to  do  with  pain- provoking  conditions  we  must 
remove  them;  if  we  are  confronted  with  inordinate 
worry  we  must  combat  it  by  the  aid  of  substitution; 
if,  finally,  we  have  to  do  with  some  morbid  condition 
of  the  organs,  resident  I  care  not  where,  it  must  be 
met  with  all  the  resources  at  our  command.  In  this 
connection,  what  has  been  said  regarding  secondary 
insomnia  may  be  recalled  with  advantage.  Above  all 
things  let  us  eschew  inordinate  drugging,  especially 
before  putting  our  patient  to  bed.  I  have  protested 
against  this  custom  and  shall  continue  to  protest 
against  it,  as  long  as  I  am  witness  of  such  flagrant 
abuses  of  sedative  substances  both  in  and  out  of 
asylums. 

And  again,  let  us  not  show  undue  readiness  to  lay 
hold  of  the  resources  of  the  drug-shop;  rather  let  us 
not  forget  that,  in  the  ordinary  aliments  of  plain  every- 
day life,  much  is  contained  which  may  prove  useful  to 
us.  I  will  merely  recall  in  this  connection  the  hop 
preparations— those  ales,  stouts,  malt  hop  toniques  and 
beers  of  German  make,  which  in  themselves  constitute 
an  armamentarium  somniferum. 

Again,  let  us  but  direct  our  attention  to  the  diges- 
tive organs;  what  possibilities  are  here  !  So  commonly 
are  digestive  disorders  either  the  immediate  cause, 
or,  at  least,  the  perpetuating  factor  of  these  derange- 
ments of  sleep,  that,  without  a  thorough  understand- 
ing of  the  stomach  in  health  and  disease,  we  should 
be  quite  unable  to  cope  with  the  secondary  conse- 
quences, involving  the  nervous  centres. 

Of  electricity,  baths,  and  cognate  adjuncts  in  treat- 
ment, a  sufficiently  extended  mention  has  already  been 
made  in  the  earlier  portions  of  the  work.  I  shall,  there- 
fore, close  this  discussion  of  the  various  questions  per- 


THE   TREATMENT    OP    INSOMNIA.  227 

taining  to  normal  and  morbid  sleep  by  observing,  once 
again,  that  the  subject  is  of  the  first  importance  to  a 
correct  understanding  and  management  of  the  painful 
affections  which  we  have  been  considering,  and  more 
particularly  of  those  pains,  located  in  and  about  the 
head,  which  constitute  such  prolific  sources  of  human 
unhappiness. 


- 


CHAPTER  XXXV. 

THE  LOCALIZATION  OF  THE  ACTION  OP  REMEDIES  UPON 
THE  BRAIN.  —  ADMINISTRATION  OP  CHEMICALS 
WHICH  ACT  IN  SMALL  DOSES,  BY  THE  NOSE  ;  THOSE 
WHICH  MUST  BE  GIVEN  IN  LARGER  AMOUNTS  TO 
PRODUCE    THEIR    EFFECTS,    BY  THE   MOUTH. -A?OM- 


PRESSION   OF   THE   INTERNAL   JUGULARS. 


In  the  previous  portions  of  this  work,  we  have  de- 
voted considerable  space  to  the  consideration  of  the 
various  theoretical  and  technical  questions  pertaining 
to  the  local  use  of  remedies  in  neuralgia.  And  let 
me  say,  that  the  prominence  accorded  this  portion  of 
the  subject  is  not  merely  a  question  of  individual  pre- 
dilection, but  rather  of  indisputable  expediency,  justi- 
fied as  it  is  by  what  we  know  of  neuritis  as  well  as  by 
the  practical  results  obtainable  in  the  clinic.  Indeed, 
so  apparent  are  the  advantages  derivable  from  the  lo- 
calization of  remedies  in  the  treatment  of  painful  affec- 
tions due  to  inflammatory  or  other  changes  of  the 
peripheral  nerves,  that  I  have  long  desired  to  extend 
the  principle  to  the  central  nervous  system,  and  more 
especially  to  the  brain.  For  it  will  occur  to  any  medi- 
cal man  of  average  perspicuity  that  the  solution  of 
this  problem  must  render  material  assistance  in  the 
management  of  various  functional  difficulties  of  in- 
tracranial origin,  not  the  least  of  which  are  certain 
idiopathic  varieties   of  headache   and   insomnia.     It 


THE   ACTION  OF   REMEDIES   UPON   THE   BRAIN.       229 

may  as  well  be  admitted,  however,  at  the  very  thresh- 
old of  these  reflections,  that  the  concentration  of  the 
effects  of  chemical  solutions  upon  the  internal  organs 
is  beset  with  difficulties,  insurmountable  ones  too,  in 
many  instances.  Thus  one  reads  in  the  journals 
from  time  to  time  accounts  of  injections  of  medicinal 
fluids  into  the  parenchyma  of  the  lung,  or  other  im- 
portant viscus,  but  the  thought  at  once  occurs  that 
these  fluids  can  at  best  produce  but  evanescent  effects 
upon  neighboring  morbid  products;  for  they — the 
fluids — are  soon  carried  away  to  distant  parts  of  the 
organism  by  the  circulation ;  and  being  thus  dissipated, 
their  local  remedial  effects  are  proportionately  attenu- 
ated. 

There  is,  however,  one  organ  which  is  exceptionally 
well  placed  with  respect  to  the  possibility  of  concen- 
trating the  action  of  remedies  upon  it ;  I  refer  to  the 
brain,  and  more  especially  to  the  cortical  layers  of  the 
cerebrum. 

To  appreciate  how  true  this  is,  it  is  necessary  to 
place  in  juxtaposition  the  following  facts: 

1.  That  the  main  blood-supply  of  the  cortex  is  con- 
tingent, or  largely  contingent,  upon  the  unobstructed 
flow  through  the  carotid  and  jugular  vessels.  Hence, 
when  the  blood  flow  in  one  or  both  of  these  sets  of 
vessels  is  arrested,  or  even  partially  arrested,  as  by 
compression,  cortical  function  is  directly  interfered 
with,  as  is  shown  by  the  confusion  of  ideas,  stupor, 
and  even  unconsciousness  engendered. 

2.  It  has  long  been  known — and  the  fact  has  fre- 
quently been  commented  upon  in  medical  literature — 
that  chemicals  applied,  especially  in  a  fluid  state,  to 
the  lining  membrane  of  the  nasal  cavity  are  speedily 


230  HEADACHE  AND  NEURALGIA. 

absorbed,  producing  in  this  way  characteristic  physio- 
logical effects.  Thus  calomel  has  been  blown  into 
the  nose,  producing  in  a  short  time  severe  salivation.1 

Narcotic  substances,  and  more  especially  morphine 
and  cocaine,  have  also  been  spread  upon  the  mucous 
membrane  of  the  nasal  cavity,  giving  rise  in  a  short 
time  to  characteristic  phenomena.  I  am  told  that  the 
effects  thus  induced  upon  the  central  nervous  system, 
and  more  especially  the  brain,  by  the  use  of  the  last- 
named  drug  are  familiar  to  rhinologists. 

The  most  reasonable  and  generally  accepted  explan- 
ation of  the  prompt  action  of  narcotic  substances  when 
used  in  this  way  is  that  which  assumes  that  the  ab- 
sorption of  the  remedy — or  at  least  the  greater  part 
of  it — takes  place  by  the  way  of  the  vessels  which 
penetrate  the  lamina  cribrosa.  If  we  admit  the 
plausibility  of  this  hypothesis,  we  shall  then  perceive 
that  remedies  administered  by  way  of  the  mucous 
membrane  of  the  nose  must  reach  the  brain,  and 
especially  the  cortex  cerebri,  in  a  more  concentrated 
state  than  when  administered  at  a  distance,  either 
bypodermically,  per  rectum,  or  by  the  stomach.  Even 
though  the  amount  of  medicinal  substance  absorbed 
be  not  great,  its  increased  concentration  at  the  seat  of 
influence  (the  brain)  must  of  necessity  result  in  physi- 
ological effects  out  of  proportion  to  the  quantity  of 
chemical  administered. 

Here  we  have  an  explanation, .  and  I  think  a  true 
one,  of  the  remarkable  cerebral  symptoms  often  pro- 

1  De  1' Administration  des  Medicaments  par  l'intermediaire  de  la 
Muqueuse  des  Fosses  nasales ;  par  Rainbert,  Journal  de  Medecine 
de  Chirurgie  et  de  Pharmacologie,  Bruxelles,  1867,  vol.  xlv. ,  p.  17, 
seventh  line  from  top  of  page. 


THE   ACTION   OF   REMEDIES   UPON  THE  BRAIN.        231 

duced  by  exceedingly  small  quantities  of  medicinal 
substances  when  applied  in  solution  to  the  eye  and 
conjunctiva. 

3.  It  is  a  fact  that,  if  narcotic  fluids  be  introduced 
into  the  nasal  cavity  in  the  manner  previously  set 
forth,  and  if  shortly  thereafter  the  flow  of  blood  in 
the  jugular  veins  be  considerably  retarded  by  the  ap- 
plication of  pressure  at  a  suitable  point  in  the  neck, 
the  effects  of  the  remedies  thus  administered  may  be 
appreciably  enhanced  and  prolonged.  This  accords 
with  all  that  I  have  been  able  to  ascertain  respecting 
the  behavior  of  remedies  when  brought  in  contact 
with  the  peripheral  nerves,  by  hypodermic  injection, 
and  maintained  there  by  occlusion  of  the  capillaries, 
or  by  constriction  of  the  artery,  veins,  or  both,  above 
the  point  of  injection  (next  the  heart).  These  pre- 
liminary observations  will,  I  trust,  make  the  principles 
involved  abundantly  clear  to  any  physician  of  average 
intelligence.  Let  me  pass,  then,  at  once,  to  the  de- 
scription of  the  simple  procedure  which  I  have  found 
most  serviceable  in  giving  practical  effect  to  the  prin- 
ciples above  enunciated.1  The  first  step  of  importance 
is  the  introduction  of  the  remedy  by  way  of  the  nose. 
To  do  this  most  effectually  the  mucous  membrane 
should  first  be  cleansed  with  warm  water,  the  latter 
serving  at  the  same  time  to  expand  the  capillaries. 
The  medicament  (morphine,  cocaine,  atropine,  etc.) 
may  then  be  introduced  in  solution  through  the  nos- 
trils by  the  aid  of  an  ordinary  medicine  dropper  or 
atomizer.  This  simple  manipulation  is  best  accom- 
plished while  the  patient  reclines  upon  his  back. 

After  the  lapse  of  ten  or  fifteen  minutes  the  second 

1  Vide  the  "  Medical  Record  "  of  December  31st,  1892. 


232 


HEADACHE  AND   NEURALGIA. 


step  may  be  proceeded  with.  This  consists  in  materi- 
ally restricting  the  lumen  of  the  internal  jugular 
veins  by  the  application  of  pressure. 

After  numerous  trials,  I  have  found  that  the  jugu- 
lars are  best  compressed  by  the  application  of  small 
dry  cups  over  the  course  of  the  vessels,  one  at  each 


Fig.  16. 


side  of  the  neck  on  a  level  with — or  a  little  below  the 
level  of — the  thyroid  cartilage. 

The  cups,  which  are  joined  together  in  front  by  an 
adjustable  steel  band,  are  about  two  inches  long  and 
half  an  inch  wide ;  they  are  made  of  metal — silver  or 
steel — and  are  held  in  place  by  an  elastic  strap,  which 
passes  around  the  neck  and  is  secured  in  place  behind 
by  the  aid  of  a  simple  buckle  (Fig.  16).  The  open  side 
of  the  cup  is,  moreover,   somewhat  concave  in  an 


THE   ACTION   OF  REMEDIES   UPON   THE   BRAIN.       233 

antero-posterior  direction,  which  admits  of  elevating 
the  veins  and  surrounding  tissues  more  effectually.  In 
this  way  it  is  possible  to  draw  the  vessels  into  the 
cups,  partially  at  least,  thus  causing  the  edges  of  the 
latter  to  act  energetically  upon  the  lumen  of  the  veins. 
The  little  dry  cups  being  maintained  in  position  over 
the  vessels  by  the  aid  of  this  simple  band,  the  air  con- 
tained in  them  is  rapidly  exhausted  by  means  of  an 
air-pump  and  vacuum-chamber,  which  exert  their  in- 
fluence upon  the  interior  of  the  cups  through  the 
intermediation  of  small,  non -collapsable  india-rubber 
tubes  (Fig.  11). 

It  is  self-evident  that  the  cohesion  of  the  compress- 
ing apparatus  thus  obtained,  as  well  as  the  elevation 
of  the  tissues  within  them,  render  valuable  assistance 
by  preventing  the  slightest  displacement  of  the  subja- 
cent vessels.  In  a  word,  the  veins,  instead  of  being 
compressed  in  a  backward  direction,  are,  as  previously 
pointed  out,  drawn  toward  and  compressed  by  the 
edges  of  the  cups.  When  all  is  properly  adjusted, 
the  elastic  bands  previously  described  may  be  tight- 
ened at  will,  thus  adding  mechanical  to  atmospheric 
pressure.  This  last  step  is  usually,  however,  unneces- 
sary, the  atmospheric  pressure  being  adequate. 

When  slight  vertigo  has  been  induced  in  this  way, 
the  evidence  is  conclusive  that  the  stasis  of  the  intra- 
cranial venous  circulation  is  sufficient  for  therapeutic 
purposes. 

There  is  no  special  limit  to  the  length  of  time  dur- 
ing which  compression  may  be  continued ;  but  from 
what  I  have  been  able  to  determine,  I  should  fancy 
that  from  twenty  minutes  to  half  or  three-quarters  of 
an  hour  are  sufficient. 


234 


HEADACHE  AND  NEURALGIA. 


Illustrative  Cases. — The  following  cases  are  cited 
with  a  view  to  illustrate  the  facility  and  rapidity  with 
which  a  variety  of  disagreeable  sensations  in  the  head, 


including  minor  degrees  of  pain  and  depression,  are 
relieved  by  resort  to  this  simple  procedure. 

Mr.  A.  C was  referred  to  me  over  three  years 


THE   ACTION   OF   REMEDIES   UPON   THE   BRAIN.        ;>'.'>:> 

ago  by  Dr.  C.  H.  Avery,  on  account  of  "severe  and 
persistent  headache.'1  When  I  first  saw  him  the 
headache  was  diffuse  in  character,  continuous,  but 
not  specially  severe.  He  informed  me,  however,  as  I 
find  by  reference  to  my  case -book,  that  at  times  he  is 
afflicted  by  sudden  and  very  severe  exacerbations  of 
pain ;  and  that,  at  such  times,  the  pain  is  almost  en- 
tirely confined  to  the  occipital  region.  There  is  very 
little  difference  between  the  pain  felt  at  night  and 
that  experienced  during  the  day. 

There  are  no  ataxic  symptoms;  the  disks  of  both 
eyes  are  normal,  but  the  pupils  are  quite  uneven,  the 
right  one  reacting  little  or  not  at  all  to  strong  light. 
I  sent  him  to  Dr.  David  Webster  for  an  opinion,  who 
wrote  me  that  there  was  undoubted  "paresis  of  the 
right  sphincter  iridis,  without  paresis  of  the  ciliary 
muscle."  A  high  degree  of  hypermetropia  was  also 
present,  for  which  Dr.  Webster  prescribed  the  neces- 
sary glasses,  to  be  worn  constantly.  Incidentally  he 
also  expressed  the  belief,  in  spite  of  the  absence  of  a 
specific  history,  that  the  mydriasis,  and  probably  also 
the  headache,  were  due  to  nervous  syphilis. 

My  own  suspicions  having  taken  a  like  direction,  I 
placed  him  at  once  upon  large  doses  of  the  iodide  of 
potash,  which  were  gradually  increased  to  the  point 
of  tolerance. 

After  several  weeks  there  was  appreciable  diminu- 
tion of  the  pain,  so  much  so  that  after  three  months 
his  visits  were  discontinued.  A  year  or  two  later  I 
saw  him  again,  and  he  stated  that  he  was  often  free 
from  pain  for  prolonged  periods — from  several  days 
to  three  or  four  weeks. 

The  paresis  of  the  right  sphincter  iridis  was  also 


236  HEADACHE  AND  NEURALGIA. 

apparently  improved,  though  the  contraction  [of  the 
pupil  was  quite  sluggish. 

So  far  as  my  case -book  reveals,  I  did  not  see  him 
again  till  October  19th,  1892,  when  he  called  at  my 
office,  complaining  of  an  unusually  severe  paroxysm, 
the  predominantly  painful  area  being  located  in  the 
frontal  region.  This  seemed  a  good  opportunity  of 
testing  the  above  method  of  locating  the  action  of 
remedies  upon  the  intracranial  structures. 

Accordingly  I  placed  the  patient  upon  his  back,  in- 
jected into  both  nostrils,  as  high  up  as  possible,  several 
drops  of  a  medicated  solution,  aggregating  morphine 
-§•  grain  and  atropine  y^-.  Ten  minutes  later,  there 
being  as  j7et  little  diminution  of  the  pain,  I  compressed 
both  jugular  veins  in  the  manner  previously  set  forth. 

The  relief  thus  afforded  excited  the  wonder  of  the 
patient,  who  declared,  after  the  lapse  of  five  minutes 
from  the  time  of  applying  the  compression  to  the 
jugulars,  that  he  "felt  no  pain." 

Later  he  informed  me  that  the  relief  thus  obtained 
was  unusually  prolonged,  there  being  little  or  no  pain 
experienced  during  the  entire  following  week.  I 
shall  have  something  to  say  regarding  the  subsequent 
history  of  this  interesting  case,  at  some  future  time. 
My  object  in  citing  it  on  the  present  occasion  is  merely 
to  show  how  promptly  a  relatively  severe  frontal 
headache  was  relieved  by  medication  by  the  nose, 
combined  with  simultaneous  compression  of  the  in- 
ternal jugulars. 

Mrs.  E.  N.  T was  referred  to  me  by  Dr.  Charles 

A.  Limeburner  for  severe,  continuous  local  headache, 
possibly  the  result  of  circumscribed  chronic  menin- 
gitis (?). 


THE   ACTION   OF  REMEDIES   UPON  THE  BRAIN.       237 

Five  months  ago,  while  walking  in  the  garden, 
patient  stepped  upon  the  prongs  of  a  rake,  which  had 
been  allowed  to  remain  in  an  upright  position,  so  that 
the  handle  leant  against  a  wall.  The  result  of  this 
action  was  to  cause  the  implement  to  fly  forward, 
inflicting  a  blow  of  such  severity  upon  the  left  side  of 
her  head  that  she  fell  to  the  ground  in  a  state  of 
partial  or  total  unconsciousness. 

On  regaining  consciousness,  she  felt  nothing  more 
than  the  soreness  which  might  naturally  have  been 
anticipated  from  the  violence  of  the  contusion.  In  a 
few  days,  however,  quite  severe  pain  set  in,  the  pain- 
ful sensations  being  deep-seated  and  corresponding 
quite  accurately  with  the  area  of  traumatism,  i.e., 
the  left  parietal  region. 

As  the  pain  was  not  relieved  by  extracranial  meas- 
ures, and  as  the  various  coal-tar  derivatives  did  not 
seem  to  help  her  much,  or,  at  all  events,  but  slowly, 
I  decided  to  endeavor  to  act  more  directly  upon  the 
intracranial  structures  by  invoking  the  method  of 
medicinal  localization  previously  described. 

Accordingly,  while  the  patient  lay  on  her  back,  I 
sprayed  into  her  nostrils  morphine,  gr.  ■§-;  atropine, 
gr.  2-^-g-.  Ten  minutes  thereafter,  patient  experiencing 
little  relief,  I  applied  the  pneumatic  compressor  over 
the  jugular  veins,  with  the  result  that,  within  five  or 
six  minutes  from  the  moment  of  its  adjustment,  there 
was  complete  cessation  of  pain.  Here,  again,  we 
have  conclusive  proof  of  the  increased  physiological 
potency  of  medicinal  solutions,  when  they  (the  solu- 
tions) are  made  to  linger  in  the  tissues  of  the  brain  or 
other  portion  of  the  central  nervous  system  by  the  aid 
of  artificially  induced  stasis  or  partial  stasis  in  the 


238  HEADACHE  AND  NEURALGIA. 

capillaries.  Such  stasis  may  be  induced  in  three  ways 
— and  I  have  tried  them  all — first,  by  compressing  the 
carotids;  secondly,  by  compressing  the  jugulars;  and 
lastly,  by  compressing  both,  the  arteries  and  veins. 
Compression  of  the  jugulars  with  the  least  possible 
interference  with  the  circulation  in  the  carotids,  will 
alone  be  discussed  on  this  occasion. 

Compression  of  the  jugulars  by  the  aid  of  the  pneu- 
matic compressor,  as  here  described,  is  not  difficult, 
especially  when  the  patient  reclines  in  a  dorsal  posi- 
tion, the  head  being  thrown  slightly  backward  so  as 
to  place  the  vessels  slightly  on  the  stretch.  This  pro- 
cedure may  be  invoked  without  hesitation  in  the 
treatment  of  individuals  under  forty  years  of  age. 

In  elderly  persons,  on  the  contrary,  where  an  athe- 
romatous condition  of  the  cerebral  blood-vessels  is 
among  the  possibilities,  it  will  be  well  either  to  aban- 
don this  mode  of  treatment,  or  to  compress  both  arteries 
(carotids)  and  veins  (jugulars)  at  once,  thus  avoiding 
an  increase  in  intra -arterial  pressure  and  consequent 
danger  of  rupture  and  hemorrhage. 

Mr.  V.  N ,  also  kindly  referred  to  me  by  Dr. 

Charles  A.  Limeburner,  has  suffered  for  several 
months  from  what  Dr.  Limeburner  believes,  and 
rightly,  I  think,  to  be  neurasthenic  headache. 

The  chief  complaint  of  this  gentleman  is  that  he  is 
beset  by  a  sensation  of  heaviness  in  the  head,  more  or 
less  continuous,  and  frequently  coupled  with  dull  pain 
at  the  vertex  and  profound  depression.  In  addition 
to  these  symptoms,  he  also  evinces  dread  of  respon- 
sibility and  society,  loss  of  memory,  especially  for 
recent  events,  inability  to  concentrate  his  attention 
for  any  length  of  time  without  discomfort ;  and,  in 


THE   ACTION   OF   REMEDIES   UPON  THE   BRAIN.       239 

short,  he  affords  a  typical  illustration  of  the  classical 
form  of  cerebral  neurasthenia. 

With  a  view  to  at  once  gain  his  confidence  by  re- 
lieving his  head  symptoms — the  vertical  pain,  the 
heaviness,  and  the  depression — I  proceeded  to  invoke 
once  more  the  aid  of  medicinal  localization. 

Instilling  into  the  nasal  cavity  a  few  drops  of  water 
containing  atropine,  y^-,  and  cocaine,  gr.  £,  I  applied 
the  pneumatic  compressor,  as  already  so  frequently 
described.  After  the  lapse  of  five  or  six  minutes 
there  was  a  decided  feeling  of  relief,  and  in  ten  or 
twelve  minutes  the  disagreeable  head  symptoms  had 
entirely  disappeared.  The  relief  in  this  case  was 
complete  during  the  following  five  or  six  days,  when 
the  procedure  was  again  repeated,  with  the  same  re- 
sults. As  a  matter  of  course,  various  measures  di- 
rected to  the  removal  of  the  exciting  cause  were 
employed  in  this  as  in  all  similar  cases,  but  as  they 
have  no  bearing  on  the  point  at  issue,  and  involve, 
moreover,  matters  which  are  part  of  the  common 
knowledge  of  the  profession,  I  have  made,  and  shall 
in  future  make,  no  detailed  reference  to  them.  As  a 
matter  of  theoretic  interest,  I  may  observe  that,  after 
instillation  of  the  atropine  and  application  of  compres- 
sion to  the  jugulars,  there  was  marked  dilatation  of 
the  pupils. 

Mr.  J.  E.  K has  been  kindly  referred  to  me  by 

Dr.  Fayette  Smith,  on  account  of  an  obstinate  form 
of  myalgia.  He  also  suffers  from  attacks  of  mental 
hebetude,  depression,  and  headache.  During  one  of 
these  seizures,  which  failed  to  yield  to  either  salol  and 
phenacetine,  or  antipyrine  and  ammonia,  I  instilled 
into  his  nostrils  morphine,  gr.  -§-,   atropine,    gr.  y^-, 


240  HEADACHE  AND  NEURALGIA. 

and  hyoscine  hydrobrom.,  gr.  ■E^T,  and  shortly  there- 
after applied  the  pneumatic  compressor  to  the  jugulars. 

As  a  result  all  the  disagreeable  symptoms  disap- 
peared within  ten  or  fifteen  minutes,  much  to  the 
delight  and  astonishment  of  the  patient,  who  had 
hitherto  failed  to  obtain  relief  from  several  remedies 
administered  in  the  conventional  manner. 

Mr.  L.  E has  been  referred  to  me  by  Dr.  David 

Webster,  on  account  of  paralysis  of  the  third  nerve, 
with  concomitant  headache,  both  phenomena  being 
doubtless  specific  in  origin.  Dr.  Webster  has  already 
obtained  some  amelioration  by  the  administration  of 
the  iodide  of  potash  combined  with  inunctions  of  the 
oleate  of  mercury.  As,  however,  there  is  still  con- 
siderable diplopia,  Dr.  Webster  feels  that  local  appli- 
cations of  electricity  should  be  tried.  Accordingly,  I 
have  made  such  applications  (of  faradism)  as  near  the 
vicinity  of  the  affected  muscles  (left  internal  and  in- 
ferior rectus)  as  possible,  employing  for  the  purpose  a 
delicate  conical  sponge  electrode. 

The  benefit  accruing  from  this  phase  of  treatment 
has  been  rapid,  the  double  vision  having  quite  disap- 
peared after  the  third  application.  I  may  add,  in 
this  connection,  that  the  eye  was  thoroughly  cocain- 
ized before  applying  the  electrode,  the  lids  being  held 
apart  by  an  ordinary  eye -speculum. 

And  this  brings  us  to  the  point  of  special  interest 
in  connection  with  the  present  argument.  As  has 
already  been  said,  this  patient  was  a  sufferer  from 
headache  of  a  persistent,  dull  character,  culminating, 
at  times,  in  exacerbations  of  considerable  severity. 

At  my  request  he  called  at  the  office  during  one  of 
these  attacks,  and  I  proceeded  at  once  to  attempt  to 


THE   ACTION  OP  REMEDIES   UPON   THE   BRAIN.       241 

abolish  the  painful  symptoms.  Spraying  the  nasal 
cavity  with  an  aqueous  solution  of  morphine,  gr.  £ ; 
cocaine,  gr.  £;  and  hyoscyamime  sulphas,  gr.  y^-,  I 
had  the  patient  remain  in  a  recumbent  position  for 
ten  or  fifteen  minutes.  At  the  end  of  this  time,  he 
stated  that  he  felt  "somewhat  better;"  but,  as  the 
relief  was  not  complete,  I  at  once  applied  the  pneu- 
matic compressor  to  the  jugulars,  when  the  patient 
almost  immediately  declared  that  all  pain  had  van- 
ished. 

Mrs.  C.   L.  V was  referred  to  me  by  the  late 

Dr.  James  R.  Learning,  on  account  of  persistent  in- 
somnia, accompanied  by  attacks  of  dull,  clawing  pain 
at  the  vertex.  As  the  patient  was  much  debilitated, 
and  as  changes  in  position — and  notably  lying  down 
and  suddenly  sitting  up — had  a  perceptible  effect  upon 
the  character  of  the  pain,  I  concluded  that  circulatory 
anomalies,  probably  anaemia,  had  something  to  do 
with  its  genesis.  Accordingly,  I  applied  the  com- 
pressor to  the  jugulars,  with  the  result  that  consider- 
able relief  was  at  once  afforded.  This  improvement 
was,  however,  evanescent;  for,  on  removal  of  the 
compressor,  it  shortly  returned. 

I  then  proceeded  as  in  the  previous  case,  instilling 
at  first  the  analgesics  and  sedatives  into  the  nasal 
cavity,  and  then  applying  the  compression  to  the 
jugulars.  Precisely  the  same  results  were  obtained 
as  in  the  previous  case — relief  from  pain,  lasting 
several  hours. 

This  case  is  interesting,  as  it  affords  incontestable 
proof  of  the  superiority  of  jugular  compression  com- 
bined with  intranasal  medication  over  jugular  com- 
pression alone. 
16 


242  HEADACHE  AND  NEUBALGIA. 

Mr.  G.  F was  referred  to  me  several  years  ago 

by  the  late  Dr.  Cornelius  K.  Agnew,  on  account  of 
spinal  neurasthenia,  accompanied  by  impairment  of 
sexual  vigor  and  insomnia.  For  several  years  patient 
had  been  harassed  by  imperative  craving  for  alcoholic 
stimulants,  the  morbid  desire  occurring  periodically, 
twice  or  thrice  yearly.  The  excesses  which  resulted 
from  these  impulses  always  left  the  patient  tremulous 
and  greatly  prostrated,  and  eventually  he  became  a 
victim  of  obstinate  and  constantly  recurring  headaches, 
in  addition  to  the  symptoms  which  had  more  espe- 
cially attracted  Dr.  Agnew 's  attention.  The  eye  con- 
ditions bore  no  special  relation  to  the  case,  consisting 
as  they  did  in  a  minor  degree  of  hypermetropia  and 
conjunctivitis.  Appropriate  glasses  had  corrected  the 
first,  and  a  simple  eye-wash  the  second  element,  so 
that  when  he  arrived  at  my  office  the  nervous  phe- 
nomena were  the  predominant,  and  indeed  the  only, 
feature.  These  I  was  able  to  abate  by  a  course  of 
treatment  of  reasonable  length ;  but  I  was  not  able  to 
overcome  the  patient's  imperative  impulses  to  periodic 
spreeing. 

Thus  it  happened  that,  for  the  last  few  years,  this 
gentleman  has  been  in  the  habit  of  seeking  me  out, 
after  one  of  these  debauches,  with  a  view  to  having 
the  results — the  head  pains,  the  tremor,  the  depres- 
sion— eliminated.  Eecently  he  called  upon  me  for  the 
usual  purpose,  suffering,  as  he  declared,  more  than 
on  former  occasions.  Especially  annoying  was  the 
sensation  of  fulness  and  pain  in  the  head,  which  made 
him  feel,  as  he  expressed  it,  "  as  though  he  would  like 
to  jump  off  the  dock."  This  seemed  a  good  opportu- 
nity to  endeavor  to  relieve  the  pain  by  concentrating 


THE   ACTION  OF  REMEDIES   UPON   THE  BRAIN.       243 

the  effect  of  the  remedies  employed  by  the  aid  of 
jugular  compression. 

As  the  patient  was  a  sufferer  from  an  old  catarrhal 
difficulty,  which  had  evidently  deprived  the  nasal  mu- 
cous membrane  of  much  of  its  absorbent  power,  I 
decided  to  administer  the  remedies  by  the  mouth.  I 
quite  realized  that  in  doing  this,  I  was  resorting  to  a 
method  inferior  to  that  previously  described,  when 
judged  by  rigid  physiological  standards;  for  these 
demand  the  placing  of  the  medicament  as  near  the 
nervous  structure  to  be  affected  as  possible.  However, 
I  could  not  help  feeling  that  the  retardation  of  the 
medicated  blood  in  this  way  would  eventuate  in  some 
enhancement  of  physiological  effect,  and  the  sequel 
proved  that  the  inference  was  a  correct  one. 

As  a  preliminary  precaution,  the  patient  was  given 
forty  drops  of  the  aromatic  spirits  of  ammonia,  and 
shortly  afterward  fifteen  grains  of  antipyrine  were 
administered.  Though  the  ammonia,  being  quickly 
absorbed,  induced  a  considerable  increase  in  the  fre- 
quency and  vehemence  of  the  heart's  action,  there 
was  no  abatement  in  the  head  symptoms — the  pain, 
hebetude,  and  depression — even  after  the  lapse  of  half 
an  hour.  And  yet  there  was  some  diaphoresis,  show- 
ing that  a  considerable  quantity  of  the  antipyrine  had 
been  absorbed. 

It  was  at  this  juncture  that  I  applied  the  pneumatic 
compressor  to  the  jugulars  in  the  usual  way. 

The  phenomena  thereby  evoked  appeared  within 
five  minutes  and  were  truly  remarkable,  if  credence 
is  to  be  given  to  the  patient's  own  statements.  He 
declared  that  the  heavy  feelings  in  the  head  had  dis- 
appeared; that  he  no  longer  felt  pain;  that  the  de- 


244  HEADACHE  AND  NEURALGIA. 

pression  had  entirely  relinquished  its  hold  upon  him ; 
and  that,  in  a  word,  he  was  "cured,"  as  he  laconically 
expressed  it. 

Obviously,  the  plan  of  treatment  just  described  has 
distinct  advantages;  for,  when  the  nasal  mucous 
membrane  is  sufficiently  healthy  to  absorb  the  medi- 
cament, the  stomach,  if  delicate,  may  be  spared  the 
reception  of  chemical  products  which  might  add  to 
the  local  derangement.  Powerful  alkaloids  are  those 
best  adapted  to  this  form  of  administration,  as  they 
may  be  given  in  small  doses,  and  are,  therefore, 
readily  taken  up  by  the  nasal  mucous  membrane, 
whose  power  of  absorption  is  limited.  Again,  there 
is  little  or  no  danger  of  setting  up  a  pernicious  habit, 
as  is  the  case  in  hypodermic  exhibitioD.  Then,  too, 
the  prompt  relief  of  intractable  symptoms  in  a  rela- 
tively short  time,  and  without  inordinate  drugging, 
is  a  notable  advantage.  Finally,  I  would  add  that 
where  the  nasal  mucous  membrane  is  not  sufficiently 
healthy  to  absorb  the  medicated  fluid  in  sufficient 
quantity  it  may  be  injected  into  or  beneath  the  intra- 
nasal mucous  membrane  by  the  aid  of  a  long  hypo- 
dermic needle  attached  to  the  syringe  conventionally 
employed.     This  I  have  done  on  one  occasion,  only. 


APPENDIX. 


EYE  STRAIN 


AS  A 


CAUSE  OF   HEADACHE 


BY 

DAVID    WEBSTER,    M.D., 

Professor  of  Ophthalmology  in  the  New  York  Polyclinic  ;  Surgeon  to  the  Manhattan 

Eye  and  Ear  Hospital ;  Consulting  Eye  Surgeon  to  the  Skin  and  Cancer 

Hospital ;  to  the  Hospital  for  the  Ruptured  and  Crippled,  to  the 

Hackensack   Hospital,  to  the   House  of  Mercy, 

New  York,  etc.,  etc. 


NEW   YORK: 

E.  B.  TREAT,  5  COOPER  UNION 

London:  H.  K.  Lewis,  136  Gower  St. 

1894 


INTRODUCTORY. 


That  headaches  are  frequently  caused  by  eye-strain 
resulting  from  various  abnormal  conditions  of  the  vis- 
ual organs  has  long  been  well  known  to  the  ophthal- 
mologist, and  is  beginning  to  be  recognized  as  a  fact 
by  the  medical  profession  generally,  as  well  as  by  the 
laity.  A  considerable  proportion  of  the  practice  of 
every  ophthalmologist  is  made  up  of  patients  referred 
to  him  by  their  family  physician,  or  coming  to  him  of 
their  own  accord,  who  are  conscious  that  their  head- 
aches are  directly  traceable  to  the  use  of  their  eyes,  and 
who  hope  to  get  relief  by  wearing  properly  selected 
glasses,  or  by  such  other  means  as  the  skilled  ophthal- 
mologist may  suggest. 

Headaches  dependent  upon  inflammatory  condi- 
tions of  the  eyes,  or  of  their  appendages,  do  not  come 
within  the  scope  of  this  paper.  We  shall  confine  our 
remarks  to  those  headaches  which  are  dependent  upon 

1.  Errors  of  refraction, 

2.  Impaired  accommodation,  and 

3.  Insufficiency  of  the  extrinsic  ocular  muscles. 


CHAPTER  I. 

HEADACHES  DEPENDENT  UPON  ERRORS  OF   REFRACTION. 

It  must  not  be  supposed  that  all  persons  who  have 
errors  of  refraction  are  subject  to  headaches,  or  other 
reflex  troubles,  caused  by  the  same.  On  the  contrary, 
this  is  true  of  a  very  small  proportion  of  such  persons. 
The  fact  is  that  very  few  persons  are  free  from  refrac- 
tive errors.  Probably  there  are  not  more  than  half  a 
dozen  emmetropic  eyes  out  of  every  hundred.  But 
the  great  majority  of  ametropes  suffer  no  especial 
inconvenience  from  their  refractive  errors.  The  fact 
remains,  however,  that  a  certain  proportion  of  such 
cases  are  the  victims  of  headaches,  and  that  nothing 
but  the  wearing  of  glasses  correcting  their  ametropia 
will  afford  them  relief.  Therefore,  in  all  cases  where 
the  patient  refers  his  headache  to  the  use  of  his  eyes, 
either  for  near  or  for  distant  vision,  he  should  be  care- 
fully examined  by  a  competent  ophthalmologist,  and 
if  ametropia  be  found  it  should  be  duly  corrected. 
Indeed,  in  every  case  of  headache,  where  all  other 
causes  have  been  excluded,  it  is  well  to  have  the  con- 
dition of  the  eyes  investigated.  For  it  is  not  uncom- 
mon to  find  a  considerable  degree  of  refractive  error, 
entailing  a  large  amount  of  ciliary  strain,  where  the 
patient  does  not  refer  any  of  his  symptoms  to  his  eyes, 
but  is  inclined  to  boast  of  the  perfection  of  those 
organs.  The  strain  is  there,  nevertheless,  but  it  makes 
itself  felt  elsewhere. 

The  following  case  illustrates  the  relief  of  headache 
by  the  constant  use  of  glasses  correcting  a  moderate 


250  HEADACHE  AND  NEURALGIA. 

amount  of  hypermetropia,  or  oversightedness,  in  a 
young  person. 

Case  I.— Feb.  9,  1887.— John  E.,  aet.  20,  student, 
complains  of  pain  in  the  eyes  after  reading,  and  on 
exposure  to  bright  light.  The  reflection  from  snow  is 
especially  trying.  He  has,  for  the  last  three  or  four 
weeks  suffered  from  headaches  after  even  moderate 
use  of  his  eyes. 

Visional  I  ;   Hm  ¥V>  b°tih  eyes. 

Orthophoria  (physiological  equilibrium  of  ocular 
muscles). 

Abduction  4°  ;  adduction  10°. 

Ophthalmoscopic  examination  shows  that  the 
media  and  fundus  are  normal. 

Feb.  17.— Under  atropia,  V  =  f£  with  +  ^,  both 
eyes.     Abduction  5°  ;  adduction  13°. 

Feb.  26. — Ordered  spectacles  +  sV  for  constant  use. 

Jan.  26,  1889.— Mr.  E.  returns,  saying  that  he  wore 
the  glasses  only  about  three  months,  when  finding  on 
trial  that  the  pain  in  his  eyes  and  head  did  not  return 
on  leaving  them  off,  he  discarded  them  entirely.  He 
is  now  married,  and  is  devoting  himself  to  the  study 
of  paleontology,  involving  a  great  deal  of  close  use  of 
the  eyes.  About  a  month  ago  the  headaches  returned. 
The  pain  is  confined  mostly  to  the  frontal  region,  and 
the  attacks  occur  about  twice  a  week.  Each  attack 
lasts  five  or  six  hours.  When  the  attack  comes  on  he 
goes  to  bed  as  soon  as  possible,  and  after  five  or  six 
hours1  suffering  he  goes  to  sleep  and  "  sleeps  it  off," 
awaking,  after  some  hours  of  sleep,  free  from  head- 
ache. These  attacks  are  sometimes  accompanied  with 
nausea,  never  with  vomiting.  The  severer  attacks 
come  on  after  prolonged  use  of  his  eyes.  The  print 
often  appears  blurred  after  he  has  read  for  a  short  time. 

V-=  -H ;  Hm  0.5  D.,  both  eyes. 


ON   EYE   STRAIN.  251 

Hyperphoria  0° ;  esophoria  2° ;  in  accommodation, 
none.  Abduction  6° ;  adduction  14°;  sursumduction, 
E.  1°  ;  L.  1°. 

No  lesion  of  media  or  fundus. 

Ordered  glasses  -f-  0.75  D.  for  all  the  time. 

April  16. — Mr.  E.  says  he  has  been  wearing  the 
glasses  constantly  as  ordered,  and  that  he  has  not  had 
more  than  three  attacks  of  headache  in  the  last  three 
months.  Two  of  these  attacks  were,  he  feels  sure,  not 
due  to  eye-strain,  but  occurred  after  imprudence  in 
diet.  The  other  attack  was  one  of  the  old  headaches, 
and  he  had  to  go  to  bed  and  "  sleep  it  off  "  as  he  used 
to  do. 

The  eyes  are  so  constituted,  and  are  in  such  rela- 
tion to  the  nervous  centres,  that  they  will  see  as  clearly 
as  possible,  independently  of  any  conscious  volition  on 
the  part  of  the  individual.  It  is  necessary  to  distinct 
vision  that  the  rays  of  light  proceeding  from  the  object 
seen  should  be  brought  to  a  focus  upon  the  retina.  In 
ordinary  distant  vision,  the  emmetropic,  or  normally 
shaped  eye  accomplishes  this  without  any  effort,  be- 
cause its  antero-posterior  diameter  bears  such  a  relation 
to  its  refractive  media  that  parallel  rays  are  brought 
to  a  focus  upon  its  retina  without  any  effort  of  adjust- 
ment, that  is,  with  its  ciliary  muscle  in  a  state  of  relax- 
ation. But  in  the  hypermetropic  eye,  which  is  shorter 
in  its  antero-posterior  diameter  than  the  emmetropic, 
when  the  ciliary  muscle  is  at  rest  the  focus  for  parallel 
rays  is  behind  the  retina.  If  it  were  possible  for  a 
hypermetrope  to  go  about  without  keeping  up  a  con- 
stant accommodative  effort  he  would  see  all  objects 
under  circles  of  dispersion,  and  his  distant  vision  would 
be  as  indistinct  as  that  of  a  myope,  or  near-sighted 
person.  This  state  of  things  actually  exists  in  all  cases 
where  the  power  of  accommodation  has  been  lost  in 


£52  HEADACHE  AND  NEURALGIA. 

hypermetropic  eyes,  either  from  old  age,  or  from  dis- 
ease, or  from  the  use  of  mydriatics  ;  and  indeed  it  is 
always  present  in  very  high  degrees  of  hypermetropia, 
the  hypermetropia  being  so  great  that  the  individual 
cannot  overcome  it  by  any  effort  of  accommodation. 
The  ciliary  muscle,  failing  to  increase  the  focalizing 
power  of  the  crystalline  lens  sufficiently  to  secure  even 
moderately  clear  vision,  gives  it  up,  so  to  speak,  and 
the  eye  contents  itself  with  such  poor  vision  as  it  can 
secure  without  any  effort.  It  is  hardly  necessary  to 
say  that  in  these  cases  of  hypermetropia,  where  the 
ciliary  muscle  remains  relaxed,  and  the  alternative  of 
blurred  vision  is  accepted,  there  is  no  headache,  so  far 
as  the  factor  that  we  are  now  speaking  of  is  concerned. 
But  in  all  moderate,  and  even  considerable,  degrees  of 
hypermetropia,  in  young  persons,  clear  vision  is  con- 
stantly kept  up  by  constantly  contracting  the  ciliary 
muscle.  In  near  work,  such  as  reading,  writing,  draw- 
ing, sewing  and  painting,  the  ciliary  muscle  of  the 
hypermetrope  has  to  do  exactly  as  much  work  as  that 
of  the  emmetrope,  in  addition  to  the  work  that  it  has 
to  perform  constantly  when  gazing  upon  distant  ob- 
jects. In  short,  the  ciliary  muscle  of  the  emmetrope 
is  at  rest  except  when  he  is  engaged  in  near  work, 
while  that  of  the  hypermetrope  is  at  work  always, 
except  when  his  eyes  are  closed,  and  does  additional 
work  while  looking  at  near  objects.  In  consequence 
of  this  constant  and  unremitting  use  the  ciliary  mus- 
cles of  the  hypermetrope  become  increased  in  size  and 
in  strength,  and  thus,  in  the  great  majority  of  cases 
are  enabled  to  bear  the  additional  strain.  But  if  the 
general  muscular  system  chances  to  be  weakened  by 
an  attack  of  illness,  or  if  the  already  overworked  cili- 
ary muscle  is  given  additional  labor,  as  in  the  case  of  a 
college  student  preparing  for  examination,  or  in  the 


ON  EYE   STRAIN.  253 

case  of  a  person  studying  any  science  enthusiastically 
day  and  night,  the  result  is  likely  to  be  headache,  which 
can  be  relieved  only  by  resting  the  ciliary  muscles. 

Thus  in  the  case  of  the  hypermetrope  reported 
above,  his  first  breakdown  was  caused  by  over-use  of 
his  eyes  at  college.  He  needed  the  relaxation  afforded 
by  glasses  only  to  bridge  him  over  that  period.  As 
soon  as  he  was  in  circumstances  to  give  his  ciliary 
muscles  a  partial  rest  the  glasses  were  laid  aside  with 
impunity.  When  he  plunged  into  work  again,  involv- 
ing extra  use  of  his  eyes,  the  headaches  returned  in  a 
worse  form  than  before,  and  he  was  compelled  to 
resume  the  use  of  spectacles. 

Case  II.— July  1,  1886. -Mrs.  Dr.  J.  J.  R.,  set.  33, 
has  all  her  life  been  subject  to  attacks  of  migraine,  but 
the  attacks  have  been  more  frequent  and  more  severe 
for  the  last  eight  or  nine  years.  Although  she  does 
not  complain  of  her  eyes  her  husband  brings  her  for 
examination  in  the  hope  that  the  headache  may  be 
found  to  be  due  to  eye-strain,  and  that  she  may  get 
that  relief,  through  treatment  of  her  eyes,  or  through 
spectacles,  which  all  other  means  have  failed  to  afford. 

R.  V  =  -f#  ;    U  +  with  +  ¥V  cylindric,  axis  90°. 

L.  V  =  U  5    M  -  with  +  eV  cylindric,  axis  90°. 

Orthophoria  ;    exophoria  in  accommodation  4°. 

Abduction  4°;  adduction  14°. 

Ophthalmoscope  ;    no  lesion. 

July  2. — Both  eyes  under  atropia: 

R.  V  =  11  +  with  +  ^  s,  C  +  rir  c,  ax.  90°. 

L..  V  =  U  +  with  +  &  s,  C  +  eV  c,  ax.  90°. 

July  12. — The  patient  accepts  only  the  cylindrics, 
the  glasses  which  improved  her  vision  before  atropia 
was  dropped  into  her  eyes. 

Glasses,  +  £s  c->  ax-  90°,  f°r  right  eye,  and  +  -^  c, 
ax.  00°,  for  left  eye,  were  prescribed  for  constant  use. 


254  HEADACHE  AND  NEURALGIA. 

January  3,  1887. — Dr.  E.  says  the  patient  has  been 
very  much  better,  but  not  entirely  free  from  her 
attacks  of  headache. 

April  26. — The  patient  states  that  her  attacks  of 
headache  are  reduced  at  least  seventy-five  per  cent., 
but  that  for  the  last  two  months  they  have  been  com- 
ing on  more  frequently  again.  The  glasses  which 
were  found  to  correct  the  total  error  of  refraction  were 
now  accepted  by  the  patient,  and  she  was  advised  to 
wear  them  instead  of  the  partial  correction  which  she 
had  been  using.  I  received  a  letter  from  her  husband, 
dated  Feb.  1,  1889,  nearly  two  years  after  the  last 
glasses  were  prescribed,  in  which  he  stated  that  she 
had  experienced  great  relief,  but  that  she  had  recently 
had  a  partial  relapse.  I  referred  him  to  another  oph- 
thalmologist in  a  distant  city  to  which  he  had  re- 
moved, and  have  not  since  heard  from  the  patient. 

The  eye-strain  which  caused  the  headache  in  this 
case  was  due  to  compound  hypermetropic  astigma- 
tism. The  unequal  contraction  of  the  ciliary  muscle 
which  is  necessary  to  produce  a  compensatory  assym- 
metry  of  the  crystalline  lens,  and  thus  to  neutralize 
the  astigmatism  of  the  cornea  and  procure  as  clear 
vision  as  possible,  is,  I  believe,  a  prolific  source  of  head- 
ache. As  in  the  case  just  related,  correction  of  the 
astigmatism  alone  is  often  sufficient  to  afford  tempo- 
rary relief.  It  generally  becomes  necessary  later  to 
correct  the  hypermetropia  also. 

Case  III.— January  28,  1889.— Sidney  G.,  get.  33, 
bachelor,  no  occupation,  was  referred  to  me  by  Dr.  J. 
Leonard  Corning  with  a  letter,  saying  :  "  Mr.  G.  is  a 
sufferer  from  general  anaemia  coupled  with  various 
nervous  symptoms,  notably  exhaustion,  vertigo  and 
painful  sensations  in  the  head.  These  phenomena  are 
particularly  pronounced  in  the  morning.  The  head 
symptoms  are  often  evoked  by  reading." 


OK    EYE   STRAIN.  255 

Mr.  G.  had  been  under  severe  emotional  strain  for 
several  years  on  account  of  the  incurable  illness  of  his 
mother,  had  kept  late  hours  and  had  studied  hard. 
His  attack  of  nervousness  and  headache  had  lasted 
for  over  six  weeks. 

E.  V  =  fjf  ;  Hm  0.50  D. 

L-  V  =  -U  5   ts  with  +  0.50  D.  cyl.,  ax.  90°. 

Orthophoria  ;   exophoria  in  accommodation,  1°. 

Abduction  6°;  adduction  29°;  sursumduction  E.  1°, 
L.  1°. 

January  30. — Under  homatropine: 

E.  V  =  f£  - ;  f§  with  +  0.50  D.  cyl.,  axis  70°. 

L.  V  =  U  ~ ;  fl  with  +  0.75  D.  cyl.,  axis  110°. 

Ophthalmoscopic  appearances  normal. 

February  1. — The  above  cylindrical  glasses,  which 
gave  him  the  best  vision  while  his  accommodation  was 
suspended  by  homatropine,  being  now  placed  before 
the  patient's  eyes,  in  trial  frames,  were  found  to  be 
comfortable  while  they  sharpened  his  vision  a  little. 
They  were,  therefore,  prescribed  for  constant  use. 

February  16. — Mr.  G.  has  been  wearing  the  glasses 
constantly  since  ordered,  and  expresses  himself  as 
much  relieved  by  them.  Dr.  Corning,  who  kept  the 
patient  under  treatment  for  some  time,  assures  me 
that  the  glasses  aided  him  greatly  in  the  restoration  of 
Mr.  G.'s  health,  and  in  the  permanent  relief  of  his 
headache. 

Thus  we  find  that  the  correction  of  ocular  errors, 
while  not  of  itself  always  sufficient  to  relieve  head 
symptoms,  is  often  an  invaluable  adjunct  to  medical 
treatment. 

Case  IV.—  Nov.  15, 1887.— G.  E.  K.,  aat.  33,  banker, 
was  referred  to  me  by  Dr.  E.  C.  Seguin,  who  wrote : 
"  He  presents  the  occipitocervical  symptoms  charac- 
teristic of  eye-strain." 


£56  HEADACHE  AND  NETJKALGIA. 

I  found  that  Mr.  K.  had  been  fitted  with  cylindrical 
glasses  by  a  distinguished  ophthalmologist  some  years 
previously,  but  that  they  failed  to  relieve  his  eye-strain 
and  headache.  The  glasses  were  +  1.25  D.  c,  axis  90°, 
both  eyes. 

R.  V  =  U  +  ;    ft  with  +  0.50  D.  c,  axis  90°. 

L.  V  =  U  +  5    it  with  -f  0.50  D.  c,  axis  90°. 

He  could  still  see  f  f  with  both  eyes  at  once  if 
+  0.50  s.  were  added  to  the  above  glasses. 

Although  there  was  insufficiency  of  the  externi  of 
1°  to  2°,  and  his  power  of  abduction  was  only  4°,  about 
half  what  it  ought  to  be,  he  rejected  prisms  as  making 
him  very  uncomfortable.  After  much  patient  testing 
I  found  +  0.75  D.  c,  ax.  90°  both,  to  be  the  glasses 
which  afforded  him  the  most  relief.  I  therefore  or- 
dered them  for  constant  use. 

April  19, 1889. — Mr.  K.  says  he  has  worn  the  glasses 
constantly  since  they  were  ordered,  except  when  exer- 
cising in  the  open  air,  and  that  since  he  has  been  wear- 
ing them  he  has  experienced  entire  relief  of  his  occipito- 
cervical pain,  except  when  he  indulges  in  over- work, 
which  easily  brings  it  on.  Recently  he  has  felt  a 
"sort  of  nervousness  "  in  and  about  his  eyes. 

Upon  testing  his  eyes  again,  it  was  found  that  they 
now  accepted  +  1  D.  c,  ax.  90°,  both.  He  was  there- 
fore directed  to  have  his  glasses  changed  accordingly. 

The  glasses  which  this  patient  had  been  trying  to 
do  his  near  work  with  before  I  saw  him  gave  him  very 
little  relief,  because  they  over-corrected  his  hyperme- 
tropic astigmatism.  I  corrected  his  manifest  astigma- 
tism and  the  glasses  were  worn  with  relief  from  the 
first.  It  was  necessary  to  change  them  for  stronger 
ones  because  some  of  the  hitherto  latent  hyperme- 
tropic astigmatism  had  been  made  manifest  by  the 
spontaneous  relaxation  of  the  ciliary  muscles. 


CHAPTER  II. 

HEADACHES    DEPENDENT    UPON    IMPAIRED 
ACCOMMODATION. 

The  most  common  form  of  impaired  accommoda- 
tion is  that  due  to  presbyopia,  or  old  sight.  The  crys- 
talline lens,  like  all  the  other  tissues  of  the  body, 
becomes  harder  as  we  grow  older,  and  therefore  less 
easily  changed  in  shape  by  the  action  of  the  ciliary 
muscle.  So  that  the  presbyope  is  compelled  to  put 
forth  additional  effort  in  order  to  focalize  upon  the 
retina  rays  of  light  coming  from  near  objects.  The 
ciliary  strain  thus  induced  often  causes  headache, 
among  other  symptoms  of  asthenopia.  The  most 
familiar  indication  of  presbyopia  is  a  tendency  to  hold 
the  book  farther  away  from  the  eyes,  and  a  blurring 
of  fine  print  at  any  distance.  When  this  occurs  the 
cause  is  generally  understood,  and  the  patient  cures 
himself  by  selecting  glasses  at  an  optician's.  But 
when  pain  in  the  eyes  and  head,  or  slight  blepharitis 
or  conjunctivitis  with  sensitiveness  to  light,  itching  of 
the  eye,  etc.,  are  the  first  symptoms  that  show  them- 
selves, the  patient  is  apt  to  apply  for  relief  to  the 
neurologist  or  ophthalmologist ;  or,  perhaps,  first  to 
his  family  physician,  who  refers  him  to  the  latter. 
We  should  not  omit,  then,  to  prescribe  glasses  for  such 
patients,  even  although  the  power  of  accommodation 
still  appears  to  be  ample.  Weak  convex  glasses  usu- 
ally give  the  required  relief,  provided  the  patient  can 
be  persuaded  to  wear  them  notwithstanding  his  ability 


258  HEADACHE  AND  NEURALGIA. 

to  read  without  them.  Weak  accommodation  oc- 
casioned by  paresis  of  the  ciliary  muscle  should  be 
supplemented  by  well-selected  spectacles.  Some  have 
reported  good  results  from  the  local  use  of  a  weak 
solution  of  eserine  or  pilocarpine  in  cases  of  weakness 
of  the  ciliary  muscle. 


CHAPTER  III. 

HEADACHES  DEPENDENT  UPON   INSUFFICIENCY  OF  THE 
EXTRINSIC   OCULAR  MUSCLES. 

A  fruitful  source  of  headache  is  the  want  of  pro- 
per balance,  or  of  physiological  equilibrium,  of  the  mus- 
cles that  move  the  eyes.  Binocular  single  vision  for 
distant  objects  should  be  maintained  without  effort. 
When  one  set  of  ocular  muscles  is  relatively  stronger 
than  the  opposing  set  an  extra  out-put  of  nervous 
energy  is  required  to  keep  both  eyes  fixed  upon  the 
same  object.  There  is  a  tendency  of  one  eye-  to  turn 
away  from  the  object  in  the  direction  of  the  stronger 
muscle.  An  extra  innervation  has  to  be  commuuicated 
to  the  weaker,  opposing  muscle.  The  eye -strain  thus 
produced,  with  the  multitude  of  consequent  asthenopic 
and  nervous  symptoms3>  can  only  be  relieved  by  restor- 
ing the  ocular  balance,  and  this  is  generally  only  to 
be  accomplished  by  the  use  of  prismatic  spectacles,  or 
by  graduated  tenotomy  of  the  too-strong  muscle. 

Case  V.— Oct.  19, 1888.— Mrs.  Dr.  0.  E.  F.,  set.  28, 
has  suffered,  for  many  years,  with  severe  pain  in  the 
back  of  the  head  and  neck,  tenderness  over  the  mas- 
toids, and  aching  of  the  eyes.  These  pains  have  been 
aggravated  by  use  of  the  eyes  for  reading  and  other 
near  work,  but  she  has  suffered  more  or  less  from  them 
most  of  the  time.  She  has  made  it  a  rule  never  to 
give  up  as  long  as  she  could  possibly  help  it,  but  some- 
times she  has  had  to  go  to  bed.  She  was  kept  under 
morphine  for  two  or  three  days  at  one  time,  but  as 


260  HEADACHE   AND   NEURALGIA. 

soon  as  the  effects  of  the  drug  passed  off  the  pains  re- 
turned as  bad  as  before.  Mrs.  F.  has  been  wearing 
spectacles  —  TVs.,  which  have  improved  her  distant 
vision  without  relieving  her  headache. 

V  =  4A  ;  fs—  with  -  3.50  D.,  each  eye. 

Hyperphoria  0°;  esophoria  2°  to  3°,  the  same  in  ac- 
commodation. Abduction  5°;  adduction  28°,  sursum- 
duction  R.  1°,  L.  1°. 

Ophthalmoscopic  examination  shows  slight  "  ero- 
sion "  at  temporal  edges  of  disks. 

Ordered — 3.D.  Oprism  1£°,  base  out,  each  eye,  for 
all  the  time. 

April  17,  1889. — Mrs.  F.  says  that  since  she  has 
been  wearing  the  glasses  ordered  last  October  she  has 
had  very  little  headache.  After  the  first  month's  use 
of  the  glasses  she  has  had  scarcely  any. 

In  this  case  it  was  not  sufficient  to  correct  the  error 
of  refraction.  It  was  also  necessary  to  take  the  strain 
off  her  too  weak  externi,  and  this  was  done  by  com- 
bining prisms  with  her  concave  glasses. 

Case  VI.  -Jan.  21,  1887.—  Miss  Ada  P.,  get.  36,  has 
all  her  life  been  subject  to  neuralgic  headaches.  They 
always  occurred  when  she  got  tired,  or  when  anything 
caused  the  blood  to  rush  to  her  head.  In  1876,  while 
attending  the  Centennial  Exhibition  at  Philadelphia, 
she  noticed  that  after  using  her  eyes  continuously  for 
two  or  three  hours  she  was  sure  to  have  pain  in  the 
back  of  her  head.  Last  winter  a  New  York  optician 
fitted  her  with  glasses  for  distant  vision  which  she  wore 
with  benefit.  Last  Christmas  she  sewed  most  of  the 
day  and  in  the  evening  read,  and  was  attacked  with  a 
feeling  of  involuntary  contraction  in  the  eyes.  Then 
pain  came  on  and  extended  from  her  eyes  to  the  root 
of  her  tongue,  to  her  left  ear,  and  to  the  back  of  her 
head  and  down  her  shoulders  and  back.    She  has  been 


ON   EYE   STRAIN.  261 

unable  to  use  her  eyes  since  without  producing  similar 
sensations. 

R.  V  =  I!]-  —  ;  emmetropic. 

L.  V  =  U  -  ;  IS  with  -  fa  cyl.,  axis  180°. 

She  is  wearing,  Rt.—  ^  c,  ax.  180°. 
lit- fa  c,  ax.  180°. 

No  insufficiency  for  the  distance. 

Esophoria  in  accommodation  13°. 

Abduction  6°;  adduction  10°. 

January  22. — 

R.  Y  =  f  l  with  -  jh;  c,  ax.  180°. 

L.  V  =  fi  with  -  ^  c,  ax.  180°. 

The  above  glasses  were  ordered  for  the  distance. 

January  2i. — Ordered  for  reading: 

Rt.  +  y^  a,  ax.  90°. 

Lft.  +  -£g  c,  ax.  90°,  3  prism  4°,  base  to  nose. 

With  these  glasses  the  patient  was  directed  to  read 
twice  daily,  beginning  with  five  minutes  and  increas- 
ing the  task  two  minutes  daily. 

February  7. — Miss  P.  is  reading  half  an  hour  morn- 
ing and  afternoon  without  disagreeable  sensations. 

February  25. — Her  tasks  have  reached  an  hour 
twice  a  day.  As  she  had  experienced  no  further 
trouble  she  was  advised  to  stop  her  regular  tasks  and 
use  her  eyes  as  occasion  might  demand. 

I  met  her  some  time  afterward,  at  the  Manhattan 
Eye  and  Ear  Hospital,  where  she  brought  a  poor 
patient  to  see  me,  and  she  said  that  her  glasses  seemed 
to  have  banished  the  headaches  permanently. 

Case  VII.— February  23, 1886.— Lizzie  V.  S.,  aet.  19, 
complains  of  pain  in  her  eyeballs  and  of  "heavy  head- 
aches." She  has  been  out  of  work  for  three  months 
on  account  of  ill-health  caused,  as  she  thinks,  by  strain- 
ing her  eyes. 

V  =  fVo  ;  U  with  -  fa,  each  eye. 


262  HEADACHE  AND  NEURALGIA. 

Orthophoria;  exophoria  in  accommodation,  14°. 

Ophthalmoscopic  examination  shows  commencing 
staphyloma  posticum  in  both  eyes. 

Under  atropia,  K.  V  =  f#  with  -  ^;  L.  V  =  f£  with 
—  y^.  Exophoria  4°.  The  right  eye  appears  to  turn 
out  at  times. 

Ordered  —  -^  s.,  O  prism  2°,  base  in,  both  eyes. 

May  28. — The  patient  states  that  she  has  worn  the 
glasses  constantly,  for  near  and  for  far.  She  has  had 
no  headaches  since  wearing  the  glasses.  She  has  had 
only  one  attack  of  pain  in  her  eyeballs  and  that  was 
not  severe  and  lasted  only  a  short  time. 

I  might  multiply  cases  in  which  headaches  had 
been  totally,  partially,  or  temporarily  relieved  by  the 
use  of  prisms  alone,  or  combined  with  spherical  or 
cylindrical  glasses.  But  that  is  unnecessary.  I  have 
cited  a  sufficient  number  to  show  that  in  all  cases  of 
headache  not  relieved  by  other  means  prisms  should 
be  tried.  Unfortunately  the  vast  majority  of  patients 
who  theoretically  need  prismatic  spectacles  and  should 
be  relieved  by  them  are  unable  to  wear  them.  The 
effects  produced  upon  vision  and  upon  the  nervous 
system  by  them  are  so  unpleasant  that  the  glasses  are 
quickly  rejected.  They  change  the  shape  of  objects  ; 
they  make  the  floor  or  side-walk  appear  to  approach 
the  eyes  or  to  recede  from  them,  thus  giving  the 
wearer  the  sensation  of  walking  up  or  down  an  inclined 
plane,  while  really  walking  on  level  ground;  they  make 
ODe  end  of  the  page  that  is  being  read  narrower  than 
the  other  end,  or  give  it  a  slanting  or  oblique  direction 
when  it  is  being  held  squarely  before  the  eyes  ;  or  they 
produce  faintness,  dizziness  or  nausea.  In  such  cases 
I  have  generally  found  it  utterly  useless  to  persuade 
the  patient  to  continue  to  wear  them.  He  is  rarely 
able  to  overcome  these  disagreeable  sensations  by  any 


ON    EYE   STRAIN.  263 

effort  of  the  will.  He  rarely  can  compel  himself  to 
ignore  them.  When  the  ophthalmic  surgeon  insists 
upon  his  continued  attempts  to  do  so  he  quietly  solves 
the  problem  for  himself  by  laying  aside  the  glasses  and 
doing  the  best  he  can  without  them,  or  by  consulting 
another  eye  surgeon,  who  prescribes  glasses  without 
prisms.  Not  infrequently  the  patient  accepts  the  pris- 
matic glasses  when  placed  before  his  eyes  in  trial- 
frames,  but  rejects  them  after  they  have  been  made 
for  him. 


CHAPTER  IV. 

GRADUATED  TENOTOMY  OP  THE   OCULAR  MUSCLES. 

Where  there  is  good  reason  to  believe  that  the 
headache  is  due  to  insufficiency  of  the  ocular  muscles 
(heterophoria),  and  prismatic  spectacles  are  rejected, 
there  only  remains  the  resort  to  graduated  tenotomy 
of  the  stronger,  opposing  muscle,  so  as  to  restore,  as 
perfectly  as  possible,  the  condition  of  physiological 
equilibrium  (orthophoria).  I  propose  to  close  this 
chapter  by  relating  a  few  cases  treated  after  this 
method. 

Case  VIII. — Miss  Alice  A.,  age  27,  consulted  me  on 
June  13,  1887.  After  using  her  eyes  she  has  headache. 
She  cannot  look  steadily  at  anything.  Her  father 
died  insane.  His  mother,  sister  and  cousin  also  were 
insane.  She  has  a  cousin  in  an  insane  asylum.  She 
broke  down  after  a  hard  winter's  work,  and  has  since 
had  headache  almost  without  intermission.  She  has 
a  feeling  in  the  back  of  the  head  and  neck  as  if  her 
head  were  being  drawn  back.  She  also  has  a  •'jump- 
ing headache  "  all  over  the  top  of  her  head.  The  jar 
of  walking  hurts  her.  Sometimes  she  feels  *' sort  of 
lost,"  as  if  she  did  not  know  anything.  For  many 
years  she  has  observed  that  her  left  pupil  is  a  little 
smaller  than  the  right.  E.  V  =  §1  —  ;  Hm  ^  ;  L.  V 
=  ft  —  ;  Hm  jV  Spectacles  +  4V  were  prescribed, 
and  she  was  put  upon  increasing  reading  tasks. 

August  20. — She  now  reads  four  hours  a  day  with 
her  glasses,     Exophoria  12°;  abduction  15°     She  has 


ON   EYE   STRAIN.  205 

single  binocular  vision  in  reading.  Tenotomy  of  left 
externus,  leaving  orthophoria.  June  21. — The  head- 
ache she  had  yesterday  before  the  operation  was  for- 
gotten after  it,  and  has  not  come  on  since. 

August  27. — She  has  done  her  usual  work  as  gov- 
erness since  last  here.  She  has  experienced  none  of 
the  ' '  drawing  feeling  "  in  the  back  of  the  head  and 
neck,  but  she  has  a  tired  feeling.  Orthophoria ;  ab- 
duction 10°;  adduction  12°. 

Case  IX. — Wm,  H.,  age  44,  married,  merchant, 
came  May  23,  1887.  Mr.  H.  was  troubled  with  headache 
all  his  life,  and  supposed  it  was  due  to  indigestion  until 
three  years  ago,  when  it  was  suggested  that  it  might 
be  due  to  eye-strain.  He  then  went  to  Dr.  Stevens, 
who  gave  him  glasses  and  exercised  his  ocular  muscles 
with  prisms.  The  glasses  relieved  his  headaches  ;  but 
recently  he  has  had  a  relapse.  If  he  reads  at  all  with- 
out his  glasses,  or  even  three  minutes  with  them, 
" his  head  is  wrong,"  and  he  becomes  intensely  sick 
all  over,  but  does  not  vomit.  His  general  health  is 
good,  his  bowels  regular ;  he  sleeps  well.  He  never 
had  any  disease  except  malaria.  E.  V  =  -§-£  ;  Hm  -^  ; 
L.  V  =  f  g  -  ;  §£  +  with  +  ^  c,  ax.  90°.  Esophoria 
3°  to  6°;  in  accommodation  15°;  no  hyperphoria  ;  ab- 
duction 2°;  adduction  23°;  sursumduction,  E.  0°,  L.  0°. 
His  glasses  are  prisms,  base  out.  May  24. — Tenotomy 
°f  left  internus,  leaving  orthophoria. 

September  20. — Mr.  M.  thinks  he  was  helped  very 
much  by  the  operation,  but  is  not  entirely  relieved. 

September  21. — Esophoria  6°;  abduction  2°;  adduc- 
tion 22°;   tenotomy  of  right  internus. 

October  10. — No  headaches  since  the  last  operation; 
wears  no  glasses,  and  uses  his  eyes  with  comfort ; 
orthophoria. 

Case  X.— Dr.  W.  S.  K.,  age  32,  consulted  Dr.  C. 


266  HEADACHE  AND   NEURALGIA. 

R.  Agnew  on  April  25,  1877.  He  stated  that  he  had 
no  trouble  with  his  eyes  until  September,  1876,  when 
neuralgic  pains  about  the  root  of  his  nose  set  in  while 
reading.  There  was  a  feeling  of  severe  tension  over  his 
brow  while  reading.  He  used  belladonna  ointment 
over  his  brows  until  his  accommodation  grew  weak, 
and  he  had  to  give  up  reading  altogether.  He  then 
became  excessively  nervous  all  over.  He  consulted 
Soelberg  Wells,  who  dilated  his  pupils  and  found  his 
fundus  normal,  but  that  he  had  Ht  3V  each  eye.  He 
has  worn  +  -^  constantly  since. 

Dr.  K.  says  his  eyes  first  "broke  down"  while 
working  all  day  with  the  ophthalmoscope  and  micro- 
scope, and  then  reading  late  at  night.  At  Christmas 
he  observed  that  he  would  become  worse  when  the 
gas  was  lighted.  He  went  to  church  on  one  occasion, 
and  the  bright  light  caused  great  infra-orbital  neural- 
gia and  neuralgia  of  the  third  division  of  the  fifth 
nerve.  This  has  been  confirmed  a  dozen  times.  Read- 
ing or  walking  in  bright  sunlight  invariably  brings 
on  pain  in  the  inferior  maxillary  region,  the  pain  being 
more  especially  referred  to  the  front  teeth  below.  His 
teeth  were  never  tender  in  mastication,  and  he  has 
only  one  carious  tooth,  the  first  molar  on  the  right 
side,  and  that  is  well  filled.  He  is  troubled  with  spasms 
about  his  internal  canthi  when  he  lies  down.  His 
digestion  seems  to  be  good.  Never  venereal  disease. 
His  father  was  rheumatic  and  perhaps  gouty.  He  says 
he  is  as  nervous  as  a  hysterical  woman.  He  jerks  and 
starts  when  he  goes  off  to  sleep.  He  suffers  from  sci- 
atica of  the  left  hip,  but  he  attributes  that  to  a  fall 
from  a  horse  when  a  boy. 

V  =  §#  each  with  +  -^.  No  insufficiency.  Oph- 
thalmoscopic examination  gives  him  excruciating  pain, 
lasting  twenty -four  hours  or  less. 


ON   EYE   STRAIN.  267 

The  patient  was  referred  to  Dr.  E.  C.  Seguin  for  an 
opinion.     Dr.  Seguin  wrote  : 

"April  25,  1877,  Dr.  K.'s  case  has  seemed  very  in- 
teresting to  me.  I  am  disposed  to  look  upon  his  hyper- 
esthesia (face  and  limbs)  as  due  primarily  to  insuffi- 
cient nutrition.  He  has  worked  hard  and  used  a  diet, 
which  I  look  upon  as  perfectly  fitted  to  develop  anaemia 
and  neuralgia.  I  would  suggest  beefsteak  and  roast 
meats  twice  a  day,  ale  or  claret  for  dinner,  and  not 
much  starchy  food.  Thompson's  solution  of  phos- 
phorus may  also  do  good,  and  relief  may  be  had  by  the 
positive  pole  of  the  galvanic  battery.  I  don't  find  the 
usual  symptoms  of  asthenopia." 

April  26.  — Hm  -^  each.  Cooper,  and  Wells,  and 
Purvis,  of  London,  all  examined  his  eyes  under  atro- 
pine and  found  that  his  Ht  was  +  ¥V  April  19.  1887. 
— The  patient  returns  to  me  with  a  letter  from  Dr.  A. 
W.  Calhoun,  of  Atlanta.  He  stated  that  he  got  no 
relief  from  his  glasses,  and  finally  discarded  them  alto- 
gether. Since  ten  years  ago  he  has  suffered  agony 
every  hour  that  he  has  been  awake,  and  he  has  been 
kept  awake  many  nights  with  pain  through  the  tem- 
ples, through  the  roots  of  the  nose,  and  through  the 
teeth  and  malar  bones.  The  main  pain  is  through  the 
malar  bones  and  nose.  No  pain  in  top  of  head  or  in 
occipital  region.  E.  V  =  f £  —  ;  fft  with  +  ^ ;  L.  V 
=  to  —  ;  f#  with  +  ¥V  No  hyperphoria  ;  esophoria 
2°;  abduction  2°;  adduction  12°.  May  7.— Esophoria 
4°;  in  accommodation  0°;  hyperphoria,  R.  1°;  abduction 
4°;  adduction  13°;  sursumduction,  R.  0°,  L.  0°.  The 
patient  was  now  referred  to  a  physician  skilled  in  dis- 
eases of  the  nose,  who  found  that  he  had  a  deviated 
septum  and  operated  upon  it.  He  also  operated  upon 
his  hypertrophied  turbinated  bone,  but  without  much 
apparent  benefit.     May  12. — Tenotomy  of  right  inter- 


268  HEADACHE  AND  NEURALGIA. 

nus,  leaving  orthophoria,  with  abduction  8° ;  as  found 
on  testing  half  an  hour  after  the  operation.  May  13. 
— Went  to  bed  last  night  with  a  freedom  from  pain 
which  he  has  not  experienced  for  years.  Esophoria  4° ; 
abduction  8°.  May  21. — Orthophoria;  abduction  T; 
adduction  19°;  much  improved.  April  2,  1888. — The 
patient  writes,  "I  have  done  a  hard  winter's  work  in 
the  college  and  with  my  practice,  and  my  eyes  have 
held  up  very  well." 

Case  XI. — Nellie  C,  age  20,  came  to  me  at  the 
Manhattan  Eye  and  Ear  Hospital  on  February  17,  1888. 
For  several  years  she  has  suffered  from  severe  head- 
aches, which  occurred  almost  every  other  day.  The 
pain  was  principally  across  the  forehead,  and  very  sel- 
dom extended  to  the  back  of  her  head.  The  headaches 
last  two  or  three  hours,  and  are  usually  brought  on  by 
reading,  but  sometimes  occur  without  any  exciting 
cause.  She  has  a  great  deal  of  facial  neuralgia  also. 
Within  the  past  seven  months  she  becomes  sleepy 
after  using  her  eyes  in  reading  or  sewing  any  length 
of  time.  She  is  very  often  taken  with  fainting  spells, 
fainting  away  and  becoming  quite  unconscious.  Eight 
days  ago  she  had  two  or  three  such  fainting  spells. 
The  first  fainting  spell  was  about  four  years  ago,  when 
she  was  attacked  with  it  while  grinding  coffee.  She 
has  usually  had  these  spells  not  more  than  once  or 
twice  a  month.  She  was  ill  during  the  whole  of  last 
summer.  She  was  cashier  in  a  store  at  the  time  and 
got  very  weak. 

R-  V  =  U  ;  U  w.  +  -h.  L.  V  =  U  ;  Em.  Hyper- 
phoria, E.  3°;  esophoria  2°;  abduction  3°;  adduction 
16°;  sursumduction,  E.  4°,  L.  5°.  February  25. — 
Divided  the  right  superior  rectus,  leaving  the  hyper- 
phoria exactly  corrected.  The  patient  fainted  twice 
during  the  operation.     February  26. — She  had  some 


ON   EYE   STRAIN.  209 

headache  after  reading  this  morning.  February  27. — 
Orthophoria  ;  abduction  6°;  adduction  16°;  sursum- 
duction,  R.  3°,  L.  3°.  March  2.— Orthophoria.  Sep- 
tember 14,  1888.— The  patient  states  that  she  has  had 
no  headaches  or  fainting  spells  since  the  operation,  a 
period  of  nearly  a  year. 

R.  V  =  U  -  ;  H  with  +  "«V  c,  ax.  90°.  L.  V  = 
§# ;  HnieV.  Orthophoria;  abduction  5°;  adduction 
16°;  sursumduction,  R.  3°,  L.  3°. 

May  11,  1889. — I  saw  this  patient  at  the  Manhattan 
Eye  and  Ear  Hospital  about  a  week  ago.  She  came  to 
report  that  she  had  had  no  headaches  or  fainting  spells 
since  I  last  saw  her,  and  that  she  considered  herself 
permanently  cured. 

Case  XII. — Rev.  F.  D.  G.,-age  30,  missionary  to 
China,  was  referred  to  me  by  Dr.  E.  C.  Seguin,  with 
the  following  letter,  dated  December  27,  1887  :  "  Rev. 
Mr.  G.  has  congestive  symptoms  about  the  head  and  a 
degree  of  nervous  prostration — now  relieved.  Since 
eight  years  he  has  noticed  occipital  pain  and  distress 
on  the  prolonged  use  of  his  eyes,  symptoms  suggestive 
to  me  of  muscular  insufficiency  in  accommodation. 
He  has  good  vision,  and  to  me,  his  eyes  are  about 
emmetropic." 

Upon  testing  Mr.  G,  I  found  :  R.  V  =  ff  ;  E.  L. 
V  =  f | ;  Hm  0.25  D.;  hyperphoria,  L.  1°;  esophoria 
1°;  exophoria  in  accommodation  4°;  abduction  4°; 
adduction  14°;  sursumduction,  R.  3°;  L.  2°,  Decem- 
ber 28. — Under  homatropine  :  R.  V  =  \ f  with  +  0.50 
D.;  L.  V  =  f|  with  +  1  D.;  hyperphoria,  L.  f;  ab- 
duction 7°. 

Ophthalmoscopic  examination  shows  physiological 
excavation  of  both  discs  and  pulsation  of  the  retinal 
veins  in  both  eyes.  There  was  no  lesion  of  either  eye 
except  a  small  white  spot  just  above  the  right  macula. 


270  HEADACHE  AND  NEURALGIA. 

December  30. — Hyperphoria,  Left  1°;  tenotomy  of  the 
left  superior  rectus,  slightly  over-correcting  the  hyper- 
phoria. January  3,  1888. — Abduction  7°.  January  6. 
— Esophoria  2°;  hyperphoria,  L.  \\  abduction  5°; 
adduction  18°;  sursumduction,  K.  4°;  L.  3°.  He  was 
instructed  to  exercise  his  interni  daily  with  prisms. 
January  9. — Abduction  1°;  adduction  50°;  esophoria 
6°;  in  accommodation  6°.  January  13.— Abduction  5°; 
esophoria  2°  to  5°.  January  20. — Abduction  7°;  hyper- 
phoria, L.  1°;  ordered  glasses  Et.  +  0.25  D.,  Lft.  + 
0.25  D.  3  1°>  Dase  down,  to  wear  all  the  time.  Janu- 
ary 27. — Abduction  6°;  hyperphoria,  L.  1°.  He  said 
he  had  experienced  relief  from  the  use  of  the  glasses, 
although  reading  with  them  for  three  hours  brought 
on  occipital  headache,  and  after  continuing  the  use  of 
them  four  hours  longer  the  headache  was  as  bad  as 
ever. 

Tenotomy  of  Bight  Inferior  Bectus,  leaving  a  slight 
over-correction.  February  10, 1888. — He  reported  that 
his  headache  had  been  better  and  that  he  read  six  or 
seven  hours  the  day  before  without  headache.  The 
tests  show  orthophoria  ;  ordered  glasses  +  0.25  D., 
both  eyes,  without  any  prism.  March  15. — The  patient 
says  his  head  symptoms  have  almost  disappeared.  For 
a  month  or  more  the  eyes  have  been  "  sore  to  the 
touch,"  and  more  or  less  red,  especially  on  rising  in 
the  morning.  The  redness  disappears  after  a  while 
He  has  had  these  inflammatory  symptoms  since  wear- 
ing the  glasses.  He  was  now  advised  to  stop  wearing 
the  glasses,  and  the  camphor  and  borax  wash  was  pre- 
scribed for  him.  Examination  showed  orthophoria. 
June  15. — I  met  the  patient  outside  my  office  and  he 
informed  me  that  he  had  no  special  trouble  with  his 
head,  although  he  had  been  hard  at  work  for  some 
months,  and  that  he  anticipated  a  speedy  return  to  his 


ON   EYE  STRAIN.  271 

missionary  duties.  October  2. — Orthophoria  ;  eso- 
phoria  in  accommodation  6°;  abduction  5°;  adduction 
30°;  sursumduction,  K.  2°;  L.  2°.  Mr.  G.  was  unavoid- 
ably detained  in  this  country.  He  considers  himself 
greatly  benefited  by  the  tenotomies,  and  is  doing  full 
work  with  his  -f  0.25  D. 

May  11,  1889. — Mr.  G.  states  that  he  has  not  been 
troubled  by  any  head  symptoms  since  I  saw  him  and 
works  as  comfortably  as  ever.  Orthophoria  ;  adduc- 
tion 7°.     He  is  about  to  return  to  his  work  in  China. 


INDEX. 


Brain,  localization  of  the 
Dreams,  209 

cerebration  of,  difficulty  of 
controlling  the,  215 

classification  of,  difficulty  at- 
tending the,  215 

comparison  of,  to  insanity, 
215 

composition  of,  209 

conceptions  of,  rapid  evolu- 
tion of,  217 

difference  between,  and  wak- 
ing thought,  215 

emotions  of,  less  hurt  fulthan 
those  of  the  waking  state, 
218 

indigestion  as  a  cause  of, 
210 

impressions  which  give  rise 
to,  209 

malposition  as  a  cause  of, 
210 

reduction  of  the  feeling  of 
personality  during  dreams, 
218 

"supernatural  agency"   in, 
210 
Electro-compression  of  the  caro- 
tids, mode  of  executing,  28 
Headache,  anaemic,  22 

alcohol  in,  24 

diet  in,  25 

elevation  of  lower  extremi- 
ties, 24 

horizontal  position  in,  25 


action  of  remedies  upon,  228 
Headache,     anaemic,     nitrite    of 
amyl  in,  24 

nitrous  oxide  in,  25 

opium  in,  24 

symptoms  of,  22 

treatment  of,  24 

cases  illustrative  of  different 
phases  of,  56 
Headache,  congestive,  26 

blisters  in,  36 

carotid  compression  in,  27 

causation  of,  26 

cold  to  the  head  in,  34 

dry-cupping  in,  36 

electro-compression    of    the 
carotids  in,  28 

epistaxis,  artificial  in,  35 

galvanic  current  in,  36 

hot  baths  in,  32 

hot  water  to  feet  in,  32 

ice- water  cap  in,  32 

symptoms  of,  26 

treatment  of,  27 
Headache,  nervous,  38 

antipyrene  in,  42 

bromides  in,  41 

causation  of,  40 

chloral  in,  41 

compression  of  scalp  and  hot- 
water  bag  in,  41 

definition  of,  38 

hyoscyamus  in,  41 

morphine  in,  41 

seclusion  in,  43 


274 


INDEX. 


Headache,  nervous,  sleep  in,  43 

symptoms  of,  39 

treatment  of,  40 
Headache,  organic,  52 

causation  of,  53 

chloral  in,  55 

diagnosis  of,  53 

iodide  of  potassium  in,  54 

morphine  in,  54 

symptoms  of,  52 

treatment  of,  53 
Headache,   sympathetic  (bilious 
headache),  47 

causation  of,  47 

intolerance  of  the  stomach  to 
remedies  in,  50 
Headache,  symptoms  of,  48 

treatment,  49 
Headache,  toxic,  44 

causation  of,  44 

defective    ventilation    as   a 
cause  of,  45 

lead  poisoning  as  a  cause  of, 
45 

pilocarpin  in,  46 

purgatives  in,  46 

treatment  of,  45 

Turkish  bath  in,  46 

ursemic    intoxication    as    a 
cause  of,  45 
Head-pains,  15 

classification  of,  20 

dura  mater  in,  19 

Erb  on,  18 

mechanism  of,  15 

Niemeyer  on,  17 

Prus  on,  19 

Symondson,  16 
Insomnia,  199 

classification  of,  199 

idiopathic,  201 

secondary,  206 

treatment  of,  222 


Insomnia,  weight,    variation    of 

in,  223 
Neuralgia,     general     considera- 
tions on,  63 

anaesthesia  in,  65 

characteristics  of,  63 

classification  of,  66 

debility  in,  63 

hyperesthesia  in,  65 

points  apophysaire,  65 

puncta  dolorosa  of,  64 

spasms,  muscular  in,  65 

vaso-motor  disturbances  in, 
65 
Neuralgia,  forms  of,  66 

cervico-brachial,  71 

cervico-occipital,  71 

coccygodynea,  76 

crural,  73 

dorso-intercostal,  74 

lumbar,  73 

lumbo-abdominal,  73 

mastodynia,  77 

muscular,  77 

osteal,  140 

periosteal,  140 

plantar,  75 

sciatic,  74 
Neuralgia,  trigeminal,  67 

(a)  supra-orbital,    or   oph- 
thalmic neuralgia,  69 

(b)  supra-maxillary  neural- 
gia, 70 

(c)  infra-maxillary  neural- 
gia, 70 

Neuralgia,  summary 

causation,  79 

diagnosis,  82 

pathology,  84 

prognosis,  86 
Neuralgia,  treatment  of,  88 

aconitia  in,  129 

arsenic  in,  132 


INDEX. 


!  \  0 


Neuralgia,  atropine,  128 

baths  in,  135 

bromide  of  potassium,  131 

cantharides  in,  133 

cases  illustrative  of  the  effi- 
cacy of  local  measures,  100 

chloral  in,  130 

chloroform  in,  129 

cocaine,  introduction  of  into 
the  skin  about  the  face,  94 

electricity  in,  119 

freezing,  local  in,  135 

heat  in,  140 

iodine  in,  133 

iron  in,  133 

local  medication  of  nerves,  93 

morphine  in,  126 

narcotics  in,  125 

ointments  in,  manner  of  em- 
ploying the,  128 

phosphorus  in,  132 

pressure  and  electricity  in, 
121 

quinine  in,  132 

remedies  adapted  to  local 
medication,  93 

remedies,  endermic  use  of  in 
neuralgia,  111 

remedies,  introduction  of  in- 
to the  integument  by  the 
aid  of  galvanism,  95 

remedies,  prolongation  of  the 
local  action  of,  97 

strychnine  in,  133 

surgical  expedients  in,  138 

turpentine  in,  133 

valerian  in,  133 

veratrine  in,  129 


Neuralgia,  zinc  in,  133 
Sleep,  187 

carotid  circulation  in,  187 

cerebro-spinal  fluid,  increase 
of  within  the  skull  in  cere- 
bral anasmia,  experiments 
of  Nounym  and  Schreiber, 
194 

definition  of,  187 

derangements  of  in  painful 
affections,  187 

essential  factors  of,  198 

excretion  of  phosphates  and 
sulphates  diminished  dur- 
ing, 197 

physiology  of,  188 

Schiff  s  experiments  on,  192 

urine  composition    modified 
by,  196 
Somnolence,  morbid,  219 

cases  illustrative  of,  220 
Spinal  irritation,  145 

cases  illustrating  the  efficacy 
of  local  medication  of  the 
cord,  161 

diagnosis  of,  149 

local  medication  of  the  cord, 
154 

local  medication  of  the  cord, 
author's  method  of  execute 
ing  the,  158 

pathology  of,  148 

symptoms  of,  145 

treatment,  151 
Spinal  irritation  due  to  shock,  169 

cases,  171 

symptoms  of,  170 


APPENDIX. 

Eye  Stkain,  a  Cause  of  Headache 


245 


[E  INTERNATIONAL 

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NERVOUS    EXHAUSTION 

[Neurasthenia] , 

Its  Hygiene,  Causes,    Symptoms  and  Treatment, 

By  GEORGE   M.   BEARD,  A.M.,  M.D., 

Formerly  Lecturer  on  Nervous  Diseases  in  the  University  of  the  City  of  New 
York  ;  Fellow  of  the  New  York  Academy  of  Medicine,  etc. 

Second  Edition  Revised  and  Enlarged  by  A.  D.  ROCKWELL,  A.M.,  M.D., 

Professor  of  Electro-Therapeutics    in  the  New  York  Post-Graduate    Medical 
School  and  Hospital,  Fellow  of  the  New  York  Academy  of  Medicine,  etc. 


Neurasthenia. — In  spite  of  its  frequency  and  importance,  although  long 
recognized  in  a  vague  way  among  tne  people  and  the  profession  under  such 
terms  as  "general  debility,"  "nervous  prostration,"  "nervous  debility," 
''nervous  asthenia,"  "  spinal  weakness,"  it  is  beginning  to  find  recognition 
in  the  literature  of  nervous  diseases.  It  is  the  most  frequent,  most  interest- 
ing, and  most  neglected  nervous  disease  of  modern  times. 

Among  specialists  and  general  practitioners  alike,  there  has  been,  on  the 
whole  subject,  a  fearful  and  wondrous  confusion  of  ideas. 

The  present  work  is  the  result  ot  the  experience  and  study  of  my  entire 
professional  life  in  the  subject  to  which  it  relates. — (From  Author's  Preface.) 

Neurasthenia  is  now  almost  a  household  word,  and  equally  with  the 
term  malaria,  affords  to  the  profession  a  convenient  refuge  when  perplexed 
at  the  recital  of  a  multitude  of  symptoms  seemingly  without  logical  connection 
or  adequate   cause. 

The  diagnosis  of  neurasthenia,  moreover,  is  often  as  satisfactory  to  the 
patient  as  it  is  easy  to  the  physician,  and  by  no  means  helps  to  reduce  the 
number  who  have  been  duly  certified  to  as  neurasthenic,  and  who  ever  after, 
with  an  air  too  conscious  to  be  concealed,  allude  to  themselves  as  the  victims 
of  nervous  exhaustion.  The  doctrine  to  be  taught  and  strongly  enforced  is 
that  many  of  these  patients  are  not  neurasthenic,  and  under  any  hardly  con- 
ceivable circumstance  could  they  become  neui asthenic.  They  do  not  belong 
to  the  tyep  out  of  which  neurasthenia  is  born,  either  mentally  or  physically. 

Many  of  them  are  unintellectual,  phlegmatic,  and  intolerably  indolent, 
and  are  pleased  at  a  diagnosis  which  touches  the  nerves  rather  than  the 
stomach,  bowels  and  liver.  Instead  of  rest,  quiet  and  soothing  draughts,  they 
need  mental  and  physical  activity,  less  rather  than  more  food,  depletion  rather 
*;han  repletion. — From  Editor  s  Preface. 


In  one  large  octavo  vol.,   nearly  300  pages.     Price,  $2.75. 
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E.  B.  TREAT,  Publisher,  5  Cooper  Union,  New  York, 


COLUMBIA  UNIVERSITY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
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DATE  BORROWED 

DATE  DUE 

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DATE  DUE 

t 

C28(638)M50 

| 

C8i 

RC598  1894 

Corning 


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